| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
201 |
62 |
$55K |
| D1110 |
Prophylaxis - adult |
711 |
706 |
$48K |
| D0330 |
Panoramic radiographic image |
258 |
258 |
$38K |
| D0274 |
Bitewings - four radiographic images |
464 |
462 |
$25K |
| D0140 |
Limited oral evaluation - problem focused |
189 |
171 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
334 |
334 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
108 |
55 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
213 |
211 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
68 |
29 |
$7K |
| D1330 |
|
292 |
292 |
$3K |
| D1206 |
Topical application of fluoride varnish |
74 |
74 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
83 |
83 |
$1K |