| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
174 |
127 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
142 |
53 |
$9K |
| D1110 |
Prophylaxis - adult |
138 |
138 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
134 |
134 |
$4K |
| D0274 |
Bitewings - four radiographic images |
152 |
152 |
$3K |
| D1120 |
Prophylaxis - child |
150 |
150 |
$3K |
| D1206 |
Topical application of fluoride varnish |
199 |
199 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
123 |
116 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
140 |
140 |
$3K |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$632.32 |
| D0272 |
Bitewings - two radiographic images |
41 |
41 |
$430.00 |
| D0220 |
Intraoral - periapical first radiographic image |
64 |
63 |
$333.25 |