| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
404 |
404 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
496 |
496 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
136 |
51 |
$9K |
| D1351 |
Sealant - per tooth |
355 |
57 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
180 |
180 |
$8K |
| D1120 |
Prophylaxis - child |
222 |
222 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
278 |
278 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
251 |
251 |
$5K |
| D0274 |
Bitewings - four radiographic images |
142 |
142 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
81 |
80 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
37 |
30 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
201 |
199 |
$2K |
| D0272 |
Bitewings - two radiographic images |
48 |
48 |
$767.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
81 |
71 |
$704.00 |
| D0270 |
|
37 |
37 |
$288.00 |
| D1999 |
|
33 |
33 |
$0.00 |