| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,303 |
558 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
343 |
280 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
896 |
383 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
827 |
125 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
187 |
97 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
1,766 |
572 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
23 |
12 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
162 |
28 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
429 |
231 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
81 |
13 |
$702.02 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$308.70 |
| D0230 |
Intraoral - periapical each additional radiographic image |
21 |
15 |
$73.38 |
| D0272 |
Bitewings - two radiographic images |
956 |
205 |
$21.11 |
| D1208 |
Topical application of fluoride, excluding varnish |
1,496 |
372 |
$0.00 |
| D0330 |
Panoramic radiographic image |
42 |
24 |
$0.00 |
| D1120 |
Prophylaxis - child |
1,098 |
239 |
$0.00 |