| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,785 |
4,785 |
$216K |
| D0120 |
Periodic oral evaluation - established patient |
8,143 |
8,143 |
$184K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,658 |
8,653 |
$110K |
| D0220 |
Intraoral - periapical first radiographic image |
9,491 |
9,479 |
$105K |
| D0210 |
Intraoral - complete series of radiographic images |
4,996 |
4,993 |
$102K |
| D1120 |
Prophylaxis - child |
2,275 |
2,275 |
$76K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,057 |
749 |
$63K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,959 |
4,959 |
$56K |
| D0274 |
Bitewings - four radiographic images |
827 |
827 |
$19K |
| D0272 |
Bitewings - two radiographic images |
289 |
289 |
$4K |
| D9990 |
|
157 |
151 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
139 |
139 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
32 |
26 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
50 |
40 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
12 |
12 |
$474.84 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$302.94 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$128.05 |
| D1999 |
|
105 |
96 |
$0.00 |