| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
743 |
732 |
$36K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
370 |
279 |
$29K |
| D0330 |
Panoramic radiographic image |
348 |
347 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
809 |
799 |
$20K |
| D7140 |
Extraction, erupted tooth or exposed root |
265 |
111 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
348 |
348 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
205 |
143 |
$12K |
| D1120 |
Prophylaxis - child |
435 |
431 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
317 |
312 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
272 |
272 |
$7K |
| D0274 |
Bitewings - four radiographic images |
234 |
230 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
533 |
513 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
56 |
43 |
$4K |
| D1206 |
Topical application of fluoride varnish |
133 |
133 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
392 |
200 |
$3K |
| D2331 |
|
18 |
13 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
84 |
41 |
$509.40 |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$288.82 |
| D1999 |
|
47 |
43 |
$0.00 |