| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,231 |
1,222 |
$81K |
| D7140 |
Extraction, erupted tooth or exposed root |
498 |
168 |
$65K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
454 |
310 |
$62K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
639 |
630 |
$35K |
| D1206 |
Topical application of fluoride varnish |
1,182 |
1,177 |
$31K |
| D0140 |
Limited oral evaluation - problem focused |
496 |
479 |
$23K |
| D0274 |
Bitewings - four radiographic images |
827 |
816 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
591 |
591 |
$19K |
| D2750 |
|
36 |
30 |
$18K |
| D0330 |
Panoramic radiographic image |
374 |
373 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,540 |
1,485 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
148 |
115 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,042 |
1,028 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
159 |
152 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
13 |
$3K |
| D2950 |
|
30 |
25 |
$3K |
| D1120 |
Prophylaxis - child |
13 |
13 |
$635.70 |
| D1330 |
|
56 |
56 |
$373.20 |