| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
351 |
351 |
$10K |
| D1351 |
Sealant - per tooth |
769 |
77 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
201 |
191 |
$9K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
63 |
28 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
343 |
338 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
281 |
278 |
$4K |
| D0330 |
Panoramic radiographic image |
107 |
106 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
238 |
237 |
$3K |
| D0274 |
Bitewings - four radiographic images |
158 |
158 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
83 |
35 |
$3K |
| D1120 |
Prophylaxis - child |
74 |
73 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
49 |
49 |
$991.87 |
| D7140 |
Extraction, erupted tooth or exposed root |
65 |
27 |
$723.58 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
13 |
$719.18 |
| D0220 |
Intraoral - periapical first radiographic image |
74 |
74 |
$595.61 |