| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
773 |
773 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
706 |
706 |
$19K |
| D0274 |
Bitewings - four radiographic images |
495 |
495 |
$13K |
| D0330 |
Panoramic radiographic image |
237 |
237 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
37 |
25 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
63 |
63 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
21 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
70 |
69 |
$645.50 |
| D0140 |
Limited oral evaluation - problem focused |
42 |
42 |
$582.98 |
| D1208 |
Topical application of fluoride, excluding varnish |
37 |
37 |
$493.50 |
| D1999 |
|
108 |
107 |
$0.00 |