| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
186 |
186 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
221 |
221 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
51 |
31 |
$13K |
| D0274 |
Bitewings - four radiographic images |
200 |
200 |
$10K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
20 |
12 |
$5K |
| D1110 |
Prophylaxis - adult |
59 |
59 |
$4K |
| D1206 |
Topical application of fluoride varnish |
73 |
73 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
12 |
12 |
$494.10 |