| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
316 |
316 |
$17K |
| D9999 |
Unspecified adjunctive procedure, by report |
88 |
58 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
305 |
305 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
79 |
52 |
$6K |
| D0274 |
Bitewings - four radiographic images |
198 |
198 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
103 |
103 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
23 |
21 |
$2K |
| D0330 |
Panoramic radiographic image |
71 |
71 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
34 |
23 |
$2K |
| D1120 |
Prophylaxis - child |
32 |
32 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
16 |
16 |
$881.60 |
| D7140 |
Extraction, erupted tooth or exposed root |
20 |
12 |
$855.00 |
| D0220 |
Intraoral - periapical first radiographic image |
54 |
54 |
$696.35 |
| D1208 |
Topical application of fluoride, excluding varnish |
43 |
43 |
$506.10 |
| D0140 |
Limited oral evaluation - problem focused |
21 |
21 |
$266.00 |