| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
344 |
341 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
394 |
393 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
337 |
334 |
$8K |
| D1110 |
Prophylaxis - adult |
93 |
90 |
$3K |
| D0274 |
Bitewings - four radiographic images |
196 |
192 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
41 |
32 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
64 |
61 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
172 |
170 |
$929.60 |
| D0230 |
Intraoral - periapical each additional radiographic image |
95 |
93 |
$520.60 |
| D7140 |
Extraction, erupted tooth or exposed root |
14 |
12 |
$508.56 |
| D0272 |
Bitewings - two radiographic images |
57 |
55 |
$488.80 |
| D0140 |
Limited oral evaluation - problem focused |
16 |
16 |
$243.00 |