| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,128 |
4,126 |
$150K |
| D0120 |
Periodic oral evaluation - established patient |
5,439 |
5,437 |
$109K |
| D0274 |
Bitewings - four radiographic images |
2,253 |
2,253 |
$44K |
| D0330 |
Panoramic radiographic image |
1,740 |
1,740 |
$42K |
| D1120 |
Prophylaxis - child |
758 |
758 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,493 |
1,493 |
$16K |
| D7140 |
Extraction, erupted tooth or exposed root |
129 |
92 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
76 |
60 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
113 |
111 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
12 |
$740.22 |
| D0272 |
Bitewings - two radiographic images |
40 |
40 |
$488.45 |
| D1206 |
Topical application of fluoride varnish |
18 |
18 |
$403.50 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$168.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
14 |
14 |
$59.05 |
| D1999 |
|
55 |
53 |
$0.00 |