| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
281 |
67 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
321 |
177 |
$18K |
| D1110 |
Prophylaxis - adult |
430 |
428 |
$15K |
| D9223 |
Deep sedation/general anesthesia - each subsequent 15 minute increment |
46 |
46 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
373 |
369 |
$12K |
| D0330 |
Panoramic radiographic image |
326 |
326 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
391 |
386 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
355 |
354 |
$7K |
| D0274 |
Bitewings - four radiographic images |
239 |
238 |
$7K |
| D9222 |
|
46 |
46 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
142 |
141 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
74 |
47 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
98 |
55 |
$4K |
| D8670 |
Periodic orthodontic treatment visit |
49 |
49 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
326 |
323 |
$3K |
| D1206 |
Topical application of fluoride varnish |
73 |
73 |
$1K |
| D1120 |
Prophylaxis - child |
22 |
22 |
$630.00 |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$240.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
14 |
13 |
$168.00 |
| D1330 |
|
33 |
33 |
$15.00 |
| D0603 |
|
12 |
12 |
$0.00 |
| D1310 |
|
24 |
24 |
$0.00 |
| D1999 |
|
176 |
168 |
$0.00 |