| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,453 |
2,447 |
$128K |
| D0120 |
Periodic oral evaluation - established patient |
2,406 |
2,397 |
$64K |
| D0274 |
Bitewings - four radiographic images |
2,157 |
2,153 |
$56K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
602 |
454 |
$49K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
256 |
183 |
$16K |
| D0330 |
Panoramic radiographic image |
204 |
204 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
150 |
150 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
72 |
72 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
22 |
13 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$175.70 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$165.20 |
| D1999 |
|
29 |
27 |
$0.00 |