| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
462 |
455 |
$18K |
| D0274 |
Bitewings - four radiographic images |
263 |
255 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
258 |
244 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
124 |
80 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
224 |
223 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
44 |
12 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
372 |
352 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
141 |
137 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
42 |
42 |
$1K |
| D0330 |
Panoramic radiographic image |
55 |
55 |
$1K |
| D1120 |
Prophylaxis - child |
30 |
30 |
$861.43 |
| D0230 |
Intraoral - periapical each additional radiographic image |
157 |
121 |
$856.50 |
| D9986 |
|
217 |
211 |
$480.00 |
| D9987 |
|
115 |
114 |
$234.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
15 |
$0.00 |
| D2740 |
Crown - porcelain/ceramic |
16 |
12 |
$0.00 |
| D9110 |
|
14 |
13 |
$0.00 |