| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
492 |
487 |
$27K |
| D1120 |
Prophylaxis - child |
427 |
425 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
667 |
663 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
433 |
425 |
$10K |
| D0274 |
Bitewings - four radiographic images |
309 |
304 |
$9K |
| D1206 |
Topical application of fluoride varnish |
398 |
396 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
87 |
66 |
$5K |
| D0330 |
Panoramic radiographic image |
132 |
130 |
$5K |
| D1321 |
|
308 |
307 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
285 |
279 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
57 |
32 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
147 |
140 |
$1K |
| D0272 |
Bitewings - two radiographic images |
56 |
56 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
29 |
26 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
31 |
29 |
$910.80 |
| D0230 |
Intraoral - periapical each additional radiographic image |
38 |
26 |
$162.06 |