| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
663 |
661 |
$64K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
791 |
412 |
$46K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
219 |
155 |
$39K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
128 |
54 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
434 |
243 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
762 |
760 |
$9K |
| D4341 |
|
105 |
37 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
132 |
131 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
17 |
16 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
51 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
53 |
53 |
$1K |
| D2331 |
|
20 |
14 |
$643.18 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$158.78 |
| D0274 |
Bitewings - four radiographic images |
655 |
653 |
$77.32 |
| D2330 |
|
14 |
12 |
$66.56 |
| D0120 |
Periodic oral evaluation - established patient |
40 |
40 |
$19.24 |
| D0220 |
Intraoral - periapical first radiographic image |
774 |
751 |
$9.22 |
| D0230 |
Intraoral - periapical each additional radiographic image |
630 |
622 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$0.00 |