| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,263 |
2,043 |
$87K |
| D0120 |
Periodic oral evaluation - established patient |
2,549 |
2,314 |
$48K |
| D0274 |
Bitewings - four radiographic images |
1,043 |
941 |
$29K |
| D0140 |
Limited oral evaluation - problem focused |
679 |
611 |
$20K |
| D0330 |
Panoramic radiographic image |
446 |
418 |
$17K |
| D1206 |
Topical application of fluoride varnish |
727 |
680 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
130 |
67 |
$6K |
| D1120 |
Prophylaxis - child |
67 |
64 |
$999.94 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
76 |
73 |
$284.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
26 |
13 |
$77.24 |
| D1999 |
|
114 |
100 |
$70.00 |
| D0191 |
|
156 |
153 |
$0.00 |
| D1330 |
|
167 |
165 |
$0.00 |