| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
717 |
709 |
$22K |
| D7140 |
Extraction, erupted tooth or exposed root |
397 |
138 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
349 |
170 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
665 |
660 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
856 |
852 |
$13K |
| D1206 |
Topical application of fluoride varnish |
688 |
685 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
491 |
470 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
276 |
250 |
$8K |
| D0274 |
Bitewings - four radiographic images |
377 |
376 |
$6K |
| D1120 |
Prophylaxis - child |
242 |
228 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
937 |
902 |
$4K |
| D0330 |
Panoramic radiographic image |
53 |
53 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
487 |
334 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
33 |
25 |
$2K |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$140.00 |
| D9995 |
|
27 |
27 |
$0.00 |