| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
983 |
959 |
$56K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
751 |
732 |
$37K |
| D0330 |
Panoramic radiographic image |
484 |
469 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
141 |
68 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
163 |
79 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
990 |
921 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
278 |
277 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
365 |
365 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
199 |
185 |
$8K |
| D2750 |
|
15 |
12 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
14 |
$2K |
| D1120 |
Prophylaxis - child |
39 |
39 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
180 |
168 |
$2K |
| D1330 |
|
37 |
37 |
$236.40 |