| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,665 |
2,665 |
$152K |
| D0120 |
Periodic oral evaluation - established patient |
2,033 |
2,033 |
$58K |
| D1120 |
Prophylaxis - child |
1,010 |
1,010 |
$43K |
| D0330 |
Panoramic radiographic image |
643 |
643 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
457 |
342 |
$24K |
| D0274 |
Bitewings - four radiographic images |
732 |
732 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
185 |
162 |
$15K |
| D0272 |
Bitewings - two radiographic images |
800 |
800 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
929 |
929 |
$13K |
| D1206 |
Topical application of fluoride varnish |
311 |
311 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
548 |
534 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
69 |
39 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
82 |
82 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
104 |
103 |
$1K |
| D2330 |
|
20 |
12 |
$1K |
| D9110 |
|
24 |
24 |
$696.00 |
| D0180 |
|
26 |
26 |
$375.00 |