| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,341 |
1,340 |
$63K |
| D0120 |
Periodic oral evaluation - established patient |
1,542 |
1,541 |
$37K |
| D0274 |
Bitewings - four radiographic images |
950 |
948 |
$26K |
| D1120 |
Prophylaxis - child |
468 |
468 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
610 |
610 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
181 |
180 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
60 |
46 |
$4K |
| D0272 |
Bitewings - two radiographic images |
220 |
220 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
66 |
51 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
63 |
62 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
27 |
13 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
38 |
37 |
$445.45 |
| D1999 |
|
160 |
152 |
$0.00 |