| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
340 |
340 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
391 |
390 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
338 |
338 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
64 |
57 |
$4K |
| D1110 |
Prophylaxis - adult |
100 |
100 |
$4K |
| D0274 |
Bitewings - four radiographic images |
220 |
220 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
135 |
134 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
39 |
32 |
$2K |
| D0272 |
Bitewings - two radiographic images |
164 |
164 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
230 |
224 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
76 |
73 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
56 |
56 |
$421.80 |