| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
387 |
384 |
$3K |
| D1110 |
Prophylaxis - adult |
527 |
525 |
$3K |
| D0274 |
Bitewings - four radiographic images |
488 |
487 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
516 |
516 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
497 |
461 |
$2K |
| D1120 |
Prophylaxis - child |
231 |
231 |
$1K |
| D1206 |
Topical application of fluoride varnish |
425 |
425 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,234 |
441 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
295 |
294 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
167 |
102 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
119 |
87 |
$805.70 |
| D0220 |
Intraoral - periapical first radiographic image |
660 |
629 |
$787.33 |
| D0272 |
Bitewings - two radiographic images |
111 |
111 |
$440.19 |
| D7140 |
Extraction, erupted tooth or exposed root |
24 |
18 |
$0.00 |