| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
254 |
239 |
$10K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
106 |
67 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
230 |
210 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
155 |
145 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
176 |
165 |
$3K |
| D1351 |
Sealant - per tooth |
63 |
30 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
113 |
101 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
129 |
112 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
210 |
187 |
$1K |
| D0274 |
Bitewings - four radiographic images |
54 |
46 |
$776.70 |
| D0230 |
Intraoral - periapical each additional radiographic image |
95 |
84 |
$463.60 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
12 |
$431.90 |
| D0272 |
Bitewings - two radiographic images |
27 |
27 |
$235.00 |