| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
697 |
694 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
783 |
777 |
$29K |
| D1206 |
Topical application of fluoride varnish |
708 |
705 |
$24K |
| D7140 |
Extraction, erupted tooth or exposed root |
148 |
52 |
$11K |
| D1354 |
|
234 |
85 |
$8K |
| D1110 |
Prophylaxis - adult |
114 |
114 |
$8K |
| D1351 |
Sealant - per tooth |
133 |
48 |
$7K |
| D0274 |
Bitewings - four radiographic images |
192 |
192 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
278 |
273 |
$3K |
| D4341 |
|
13 |
12 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
47 |
47 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
232 |
232 |
$2K |
| D0330 |
Panoramic radiographic image |
42 |
42 |
$2K |
| D4355 |
|
14 |
14 |
$954.20 |
| D1999 |
|
58 |
58 |
$0.00 |
| D0602 |
|
223 |
166 |
$0.00 |
| D0603 |
|
321 |
229 |
$0.00 |
| D0601 |
|
309 |
222 |
$0.00 |