| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,415 |
2,414 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
3,070 |
3,069 |
$3K |
| D0274 |
Bitewings - four radiographic images |
1,739 |
1,739 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
474 |
298 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
3,413 |
3,370 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
288 |
204 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,528 |
2,507 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
513 |
513 |
$999.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
573 |
573 |
$890.00 |
| D1120 |
Prophylaxis - child |
256 |
256 |
$668.75 |
| D0140 |
Limited oral evaluation - problem focused |
494 |
490 |
$542.00 |
| D0330 |
Panoramic radiographic image |
87 |
87 |
$167.50 |
| D7140 |
Extraction, erupted tooth or exposed root |
21 |
12 |
$76.25 |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$30.00 |
| D0210 |
Intraoral - complete series of radiographic images |
93 |
93 |
$0.00 |
| D1999 |
|
49 |
48 |
$0.00 |
| D9430 |
|
73 |
72 |
$0.00 |