| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
116 |
114 |
$114.32 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
12 |
$114.30 |
| D0274 |
Bitewings - four radiographic images |
123 |
121 |
$105.16 |
| D1206 |
Topical application of fluoride varnish |
225 |
224 |
$74.30 |
| D0120 |
Periodic oral evaluation - established patient |
90 |
90 |
$65.16 |
| D0220 |
Intraoral - periapical first radiographic image |
115 |
114 |
$45.72 |
| D1110 |
Prophylaxis - adult |
69 |
69 |
$38.86 |
| D0270 |
|
117 |
116 |
$36.56 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
62 |
62 |
$29.72 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
28 |
12 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
26 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
25 |
12 |
$0.00 |