| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
46 |
24 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
221 |
213 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
14 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
63 |
61 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
29 |
28 |
$756.32 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$516.60 |
| D0120 |
Periodic oral evaluation - established patient |
16 |
16 |
$457.80 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$410.67 |