| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
219 |
209 |
$11K |
| D1110 |
Prophylaxis - adult |
278 |
269 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
119 |
80 |
$7K |
| D0274 |
Bitewings - four radiographic images |
253 |
251 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
93 |
64 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
196 |
194 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
89 |
89 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
40 |
26 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
93 |
93 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
209 |
188 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
112 |
60 |
$914.00 |
| D0140 |
Limited oral evaluation - problem focused |
27 |
27 |
$680.85 |
| D1120 |
Prophylaxis - child |
15 |
15 |
$319.00 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$158.00 |