| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,994 |
1,950 |
$79K |
| D0330 |
Panoramic radiographic image |
1,214 |
797 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
1,695 |
1,673 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,400 |
1,009 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,459 |
1,445 |
$26K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
281 |
212 |
$23K |
| D7140 |
Extraction, erupted tooth or exposed root |
594 |
185 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
326 |
188 |
$21K |
| D1120 |
Prophylaxis - child |
552 |
550 |
$17K |
| D0272 |
Bitewings - two radiographic images |
333 |
326 |
$6K |
| D0274 |
Bitewings - four radiographic images |
274 |
269 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
49 |
49 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
14 |
12 |
$347.62 |
| D9630 |
|
27 |
24 |
$238.44 |
| D1999 |
|
33 |
28 |
$0.00 |