| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,201 |
2,199 |
$2K |
| D0272 |
Bitewings - two radiographic images |
1,924 |
1,922 |
$2K |
| D1110 |
Prophylaxis - adult |
1,342 |
1,340 |
$2K |
| D1120 |
Prophylaxis - child |
545 |
545 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,832 |
1,824 |
$942.25 |
| D0220 |
Intraoral - periapical first radiographic image |
2,304 |
2,276 |
$887.50 |
| D1208 |
Topical application of fluoride, excluding varnish |
881 |
881 |
$400.00 |
| D0330 |
Panoramic radiographic image |
333 |
333 |
$362.25 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
197 |
196 |
$362.00 |
| D2140 |
|
55 |
26 |
$0.00 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
28 |
14 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
13 |
12 |
$0.00 |
| D8670 |
Periodic orthodontic treatment visit |
409 |
409 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
26 |
13 |
$0.00 |