| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
294 |
113 |
$19K |
| D1110 |
Prophylaxis - adult |
520 |
516 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
733 |
728 |
$15K |
| D0274 |
Bitewings - four radiographic images |
330 |
329 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,205 |
446 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
521 |
513 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
53 |
43 |
$3K |
| D1310 |
|
130 |
124 |
$932.85 |
| D1330 |
|
130 |
124 |
$932.24 |
| D2331 |
|
15 |
13 |
$900.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
14 |
$900.00 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$390.00 |
| D1320 |
|
15 |
15 |
$165.00 |