| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
230 |
230 |
$10K |
| D1351 |
Sealant - per tooth |
121 |
62 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
247 |
247 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
223 |
223 |
$6K |
| D1110 |
Prophylaxis - adult |
79 |
79 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
49 |
25 |
$3K |
| D0274 |
Bitewings - four radiographic images |
177 |
177 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
112 |
112 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
57 |
49 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
313 |
310 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
272 |
270 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
49 |
47 |
$936.88 |
| D0272 |
Bitewings - two radiographic images |
45 |
45 |
$465.78 |