| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
234 |
234 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
96 |
52 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
222 |
222 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
111 |
109 |
$3K |
| D1120 |
Prophylaxis - child |
47 |
47 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
57 |
57 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
284 |
278 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
27 |
27 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
28 |
15 |
$1K |
| D0274 |
Bitewings - four radiographic images |
92 |
92 |
$984.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
12 |
$770.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
214 |
213 |
$660.00 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
15 |
$585.00 |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$140.00 |
| D1330 |
|
29 |
29 |
$0.00 |
| D9986 |
|
32 |
32 |
$0.00 |