| Code | Description | Claims | Bene. Records | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
218 |
216 |
$7K |
| D0330 |
Panoramic radiographic image |
175 |
132 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
240 |
204 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
272 |
232 |
$3K |
| D1206 |
Topical application of fluoride varnish |
85 |
85 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
105 |
104 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
73 |
70 |
$981.38 |
| D1120 |
Prophylaxis - child |
16 |
16 |
$492.32 |
| D0220 |
Intraoral - periapical first radiographic image |
80 |
78 |
$392.31 |
| D0274 |
Bitewings - four radiographic images |
15 |
15 |
$331.20 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
31 |
15 |
$0.00 |
| D1999 |
|
17 |
16 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
49 |
28 |
$0.00 |