| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
193 |
191 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
151 |
150 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
214 |
213 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
135 |
134 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
48 |
19 |
$2K |
| D1120 |
Prophylaxis - child |
102 |
102 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
121 |
120 |
$2K |
| D0274 |
Bitewings - four radiographic images |
101 |
100 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
35 |
25 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
227 |
133 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
204 |
199 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
24 |
18 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
32 |
31 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
13 |
$1K |
| D1330 |
|
50 |
50 |
$429.56 |
| D9986 |
|
39 |
38 |
$0.00 |