| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
171 |
170 |
$4K |
| D1110 |
Prophylaxis - adult |
108 |
106 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
65 |
32 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
55 |
27 |
$2K |
| D0274 |
Bitewings - four radiographic images |
89 |
87 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
78 |
78 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
244 |
238 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
35 |
33 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
183 |
138 |
$840.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
13 |
12 |
$780.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
14 |
$768.15 |
| D0140 |
Limited oral evaluation - problem focused |
31 |
29 |
$654.82 |
| D1206 |
Topical application of fluoride varnish |
37 |
37 |
$540.00 |
| D0272 |
Bitewings - two radiographic images |
22 |
22 |
$220.00 |