| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
92 |
92 |
$2K |
| D1110 |
Prophylaxis - adult |
93 |
91 |
$2K |
| D0272 |
Bitewings - two radiographic images |
100 |
100 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
84 |
84 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
59 |
59 |
$811.02 |
| D0120 |
Periodic oral evaluation - established patient |
54 |
54 |
$526.50 |
| D1120 |
Prophylaxis - child |
32 |
32 |
$522.90 |
| D2140 |
|
23 |
15 |
$457.50 |
| D7140 |
Extraction, erupted tooth or exposed root |
19 |
16 |
$399.00 |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
16 |
12 |
$362.40 |