| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
906 |
902 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
1,264 |
1,259 |
$37K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
181 |
129 |
$20K |
| D1120 |
Prophylaxis - child |
389 |
389 |
$16K |
| D0274 |
Bitewings - four radiographic images |
424 |
421 |
$16K |
| D1206 |
Topical application of fluoride varnish |
835 |
835 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
82 |
51 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
171 |
171 |
$9K |
| D0330 |
Panoramic radiographic image |
108 |
108 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
64 |
45 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
58 |
58 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
17 |
12 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
219 |
218 |
$3K |
| D0272 |
Bitewings - two radiographic images |
97 |
97 |
$2K |
| D1330 |
|
616 |
608 |
$2K |
| D0603 |
|
355 |
347 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
117 |
114 |
$2K |
| D0270 |
|
44 |
43 |
$581.82 |
| D0602 |
|
31 |
30 |
$170.00 |
| D1999 |
|
12 |
12 |
$0.00 |