| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
663 |
663 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
822 |
822 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
176 |
130 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
215 |
145 |
$14K |
| D1206 |
Topical application of fluoride varnish |
668 |
668 |
$11K |
| D0274 |
Bitewings - four radiographic images |
206 |
206 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
123 |
123 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
117 |
117 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
16 |
12 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
40 |
40 |
$2K |
| D1120 |
Prophylaxis - child |
39 |
39 |
$1K |
| D0330 |
Panoramic radiographic image |
24 |
24 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
79 |
77 |
$986.37 |