| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
125 |
123 |
$85.00 |
| D0210 |
Intraoral - complete series of radiographic images |
168 |
158 |
$50.00 |
| D1206 |
Topical application of fluoride varnish |
179 |
178 |
$50.00 |
| D9430 |
|
128 |
121 |
$40.00 |
| D0220 |
Intraoral - periapical first radiographic image |
180 |
125 |
$25.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
190 |
179 |
$20.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
31 |
24 |
$0.00 |
| D0603 |
|
182 |
173 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
12 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
15 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
48 |
40 |
$0.00 |
| D1120 |
Prophylaxis - child |
17 |
17 |
$0.00 |
| D0270 |
|
13 |
13 |
$0.00 |