| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
301 |
301 |
$19K |
| D0330 |
Panoramic radiographic image |
188 |
188 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
138 |
111 |
$15K |
| D7140 |
Extraction, erupted tooth or exposed root |
113 |
42 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
326 |
325 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
240 |
240 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
72 |
59 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
141 |
141 |
$5K |
| D1120 |
Prophylaxis - child |
140 |
140 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
159 |
159 |
$5K |
| D0274 |
Bitewings - four radiographic images |
102 |
102 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
324 |
125 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
278 |
272 |
$3K |
| D1351 |
Sealant - per tooth |
42 |
12 |
$2K |
| D1206 |
Topical application of fluoride varnish |
39 |
38 |
$724.45 |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
25 |
$539.05 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$247.56 |
| D1999 |
|
73 |
64 |
$0.00 |