| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
798 |
796 |
$57K |
| D1120 |
Prophylaxis - child |
140 |
140 |
$10K |
| D0330 |
Panoramic radiographic image |
53 |
53 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
254 |
254 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
100 |
36 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
96 |
30 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
12 |
$1K |
| D2160 |
|
28 |
13 |
$1K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
38 |
14 |
$921.30 |
| D0140 |
Limited oral evaluation - problem focused |
73 |
72 |
$753.75 |
| D0274 |
Bitewings - four radiographic images |
600 |
598 |
$398.82 |
| D0120 |
Periodic oral evaluation - established patient |
641 |
641 |
$164.97 |
| D1351 |
Sealant - per tooth |
51 |
13 |
$90.32 |
| D0272 |
Bitewings - two radiographic images |
94 |
94 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
23 |
12 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
158 |
153 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
782 |
780 |
$-503.98 |