| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,080 |
1,080 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
1,249 |
1,249 |
$28K |
| D0274 |
Bitewings - four radiographic images |
810 |
810 |
$21K |
| D7140 |
Extraction, erupted tooth or exposed root |
107 |
70 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
166 |
165 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
69 |
44 |
$6K |
| D0330 |
Panoramic radiographic image |
69 |
69 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
276 |
267 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
121 |
121 |
$2K |
| D0272 |
Bitewings - two radiographic images |
40 |
40 |
$719.72 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$486.00 |