| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
477 |
472 |
$10K |
| D1110 |
Prophylaxis - adult |
264 |
260 |
$7K |
| D0274 |
Bitewings - four radiographic images |
415 |
411 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
124 |
73 |
$7K |
| D1120 |
Prophylaxis - child |
283 |
282 |
$6K |
| D1206 |
Topical application of fluoride varnish |
398 |
396 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
600 |
586 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
228 |
228 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
794 |
465 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
81 |
55 |
$3K |
| D1351 |
Sealant - per tooth |
108 |
25 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
46 |
27 |
$2K |
| D0272 |
Bitewings - two radiographic images |
145 |
145 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
74 |
73 |
$2K |
| D0330 |
Panoramic radiographic image |
24 |
24 |
$802.45 |