| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
239 |
239 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
225 |
224 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
74 |
51 |
$4K |
| D9110 |
|
99 |
99 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
63 |
63 |
$3K |
| D0274 |
Bitewings - four radiographic images |
100 |
100 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
42 |
27 |
$2K |
| D1120 |
Prophylaxis - child |
77 |
77 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
86 |
86 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
119 |
119 |
$885.71 |
| D7140 |
Extraction, erupted tooth or exposed root |
17 |
14 |
$784.89 |
| D1208 |
Topical application of fluoride, excluding varnish |
45 |
45 |
$750.00 |
| D1206 |
Topical application of fluoride varnish |
40 |
40 |
$703.02 |
| D1330 |
|
76 |
76 |
$400.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
30 |
29 |
$268.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$200.54 |