| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
49 |
48 |
$455.00 |
| D1206 |
Topical application of fluoride varnish |
82 |
82 |
$380.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
58 |
42 |
$284.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
27 |
$266.00 |
| D0220 |
Intraoral - periapical first radiographic image |
89 |
88 |
$260.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
107 |
44 |
$189.00 |
| D0274 |
Bitewings - four radiographic images |
30 |
30 |
$174.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
16 |
13 |
$160.00 |
| D0120 |
Periodic oral evaluation - established patient |
53 |
53 |
$140.00 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$80.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
38 |
27 |
$56.00 |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$47.00 |
| D1310 |
|
63 |
63 |
$0.00 |