| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
331 |
331 |
$8K |
| D1110 |
Prophylaxis - adult |
200 |
200 |
$7K |
| D0274 |
Bitewings - four radiographic images |
259 |
259 |
$7K |
| D1120 |
Prophylaxis - child |
195 |
195 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
95 |
57 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
100 |
58 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
169 |
169 |
$5K |
| D1351 |
Sealant - per tooth |
191 |
34 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
72 |
72 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
133 |
133 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
35 |
25 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
257 |
255 |
$2K |
| D1206 |
Topical application of fluoride varnish |
100 |
100 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
213 |
195 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
30 |
28 |
$909.08 |
| D0272 |
Bitewings - two radiographic images |
54 |
54 |
$868.80 |
| D1999 |
|
195 |
187 |
$0.00 |