| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
876 |
822 |
$11K |
| D1110 |
Prophylaxis - adult |
416 |
410 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
418 |
409 |
$5K |
| D1120 |
Prophylaxis - child |
334 |
328 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
275 |
272 |
$4K |
| D1206 |
Topical application of fluoride varnish |
691 |
620 |
$3K |
| D0274 |
Bitewings - four radiographic images |
273 |
269 |
$3K |
| D0603 |
|
877 |
824 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
146 |
146 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
441 |
418 |
$2K |
| D1354 |
|
1,482 |
355 |
$1K |
| D1999 |
|
176 |
165 |
$679.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
79 |
56 |
$619.00 |
| D1351 |
Sealant - per tooth |
147 |
35 |
$600.00 |
| D2331 |
|
21 |
13 |
$529.35 |
| D2940 |
|
61 |
52 |
$480.00 |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
39 |
31 |
$470.00 |
| D0602 |
|
348 |
328 |
$407.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
136 |
115 |
$398.85 |
| D0272 |
Bitewings - two radiographic images |
109 |
107 |
$324.13 |
| D7140 |
Extraction, erupted tooth or exposed root |
29 |
25 |
$316.00 |
| D4355 |
|
42 |
42 |
$312.00 |
| D0601 |
|
234 |
222 |
$275.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
125 |
121 |
$240.00 |
| D2140 |
|
15 |
12 |
$117.00 |
| D0270 |
|
73 |
70 |
$56.00 |
| D1330 |
|
766 |
741 |
$0.00 |
| D1310 |
|
244 |
239 |
$0.00 |