| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
462 |
462 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
560 |
560 |
$10K |
| D1110 |
Prophylaxis - adult |
259 |
259 |
$10K |
| D1206 |
Topical application of fluoride varnish |
607 |
607 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
234 |
230 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
42 |
12 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
324 |
316 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
68 |
36 |
$4K |
| D0274 |
Bitewings - four radiographic images |
123 |
123 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
290 |
151 |
$2K |
| D0330 |
Panoramic radiographic image |
46 |
46 |
$2K |
| D0272 |
Bitewings - two radiographic images |
85 |
85 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
32 |
32 |
$775.85 |