| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
347 |
347 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
171 |
138 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
405 |
405 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
119 |
56 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
144 |
112 |
$7K |
| D0274 |
Bitewings - four radiographic images |
179 |
179 |
$5K |
| D1120 |
Prophylaxis - child |
78 |
78 |
$2K |
| D0330 |
Panoramic radiographic image |
54 |
54 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
27 |
26 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
54 |
54 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$280.00 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$234.00 |