| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
376 |
374 |
$3K |
| D1206 |
Topical application of fluoride varnish |
440 |
437 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
580 |
547 |
$990.28 |
| D0274 |
Bitewings - four radiographic images |
289 |
287 |
$969.72 |
| D0230 |
Intraoral - periapical each additional radiographic image |
577 |
415 |
$710.41 |
| D0120 |
Periodic oral evaluation - established patient |
271 |
271 |
$375.68 |
| D7140 |
Extraction, erupted tooth or exposed root |
239 |
124 |
$86.62 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
182 |
181 |
$77.67 |
| D0330 |
Panoramic radiographic image |
163 |
162 |
$69.42 |
| D0140 |
Limited oral evaluation - problem focused |
159 |
155 |
$69.04 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
146 |
104 |
$68.24 |
| D2330 |
|
19 |
12 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
106 |
84 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
78 |
78 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
226 |
155 |
$0.00 |
| D1330 |
|
65 |
65 |
$0.00 |
| D2331 |
|
36 |
26 |
$0.00 |
| D1120 |
Prophylaxis - child |
124 |
124 |
$0.00 |