| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
365 |
159 |
$30K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
250 |
155 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
208 |
82 |
$15K |
| D1110 |
Prophylaxis - adult |
232 |
231 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
120 |
119 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
254 |
254 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
113 |
75 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
89 |
64 |
$7K |
| D0274 |
Bitewings - four radiographic images |
183 |
182 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
155 |
154 |
$4K |
| D1206 |
Topical application of fluoride varnish |
158 |
158 |
$3K |
| D0330 |
Panoramic radiographic image |
58 |
58 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
86 |
85 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
345 |
219 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
234 |
233 |
$2K |
| D2950 |
|
18 |
17 |
$1K |
| D0350 |
|
27 |
27 |
$653.88 |
| D1120 |
Prophylaxis - child |
16 |
16 |
$320.00 |