| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
303 |
302 |
$27K |
| D1110 |
Prophylaxis - adult |
332 |
331 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
235 |
143 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
448 |
447 |
$6K |
| D1120 |
Prophylaxis - child |
149 |
149 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
26 |
17 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
56 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
73 |
41 |
$883.56 |
| D0274 |
Bitewings - four radiographic images |
73 |
73 |
$814.53 |
| D0140 |
Limited oral evaluation - problem focused |
25 |
25 |
$563.48 |
| D0120 |
Periodic oral evaluation - established patient |
323 |
323 |
$166.47 |
| D1351 |
Sealant - per tooth |
88 |
14 |
$104.15 |
| D0330 |
Panoramic radiographic image |
58 |
58 |
$103.96 |
| D1206 |
Topical application of fluoride varnish |
259 |
259 |
$40.65 |
| D0220 |
Intraoral - periapical first radiographic image |
512 |
505 |
$9.22 |
| D0230 |
Intraoral - periapical each additional radiographic image |
464 |
319 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
40 |
40 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$0.00 |