| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,649 |
1,628 |
$58K |
| D0120 |
Periodic oral evaluation - established patient |
2,139 |
2,126 |
$34K |
| D7140 |
Extraction, erupted tooth or exposed root |
272 |
139 |
$17K |
| D1120 |
Prophylaxis - child |
385 |
385 |
$12K |
| D0272 |
Bitewings - two radiographic images |
550 |
540 |
$11K |
| D1206 |
Topical application of fluoride varnish |
571 |
569 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
181 |
161 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
44 |
38 |
$5K |
| D0330 |
Panoramic radiographic image |
81 |
81 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
150 |
140 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
41 |
38 |
$819.39 |
| D0274 |
Bitewings - four radiographic images |
26 |
26 |
$0.00 |