| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
571 |
563 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
638 |
632 |
$24K |
| D1206 |
Topical application of fluoride varnish |
573 |
565 |
$19K |
| D7140 |
Extraction, erupted tooth or exposed root |
164 |
82 |
$8K |
| D0274 |
Bitewings - four radiographic images |
112 |
112 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
60 |
60 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
73 |
73 |
$1K |
| D0330 |
Panoramic radiographic image |
31 |
31 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
78 |
77 |
$534.10 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$492.00 |