| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
423 |
289 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
260 |
146 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
416 |
245 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
175 |
43 |
$7K |
| D0274 |
Bitewings - four radiographic images |
204 |
138 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
164 |
134 |
$3K |
| D1206 |
Topical application of fluoride varnish |
251 |
140 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
36 |
14 |
$954.00 |
| D0140 |
Limited oral evaluation - problem focused |
33 |
17 |
$373.32 |
| D1120 |
Prophylaxis - child |
28 |
17 |
$311.94 |
| D0220 |
Intraoral - periapical first radiographic image |
40 |
28 |
$291.06 |
| D1999 |
|
245 |
102 |
$0.00 |