| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
646 |
646 |
$41K |
| D0140 |
Limited oral evaluation - problem focused |
632 |
626 |
$12K |
| D1120 |
Prophylaxis - child |
140 |
140 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
148 |
103 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
71 |
71 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
52 |
25 |
$5K |
| D0330 |
Panoramic radiographic image |
88 |
88 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
326 |
326 |
$429.57 |
| D0274 |
Bitewings - four radiographic images |
296 |
296 |
$140.90 |
| D0120 |
Periodic oral evaluation - established patient |
672 |
672 |
$96.36 |
| D1208 |
Topical application of fluoride, excluding varnish |
632 |
632 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
169 |
157 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
530 |
518 |
$0.00 |