| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
521 |
520 |
$26K |
| D1110 |
Prophylaxis - adult |
644 |
641 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
172 |
138 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
821 |
815 |
$8K |
| D0274 |
Bitewings - four radiographic images |
1,290 |
1,280 |
$6K |
| D1120 |
Prophylaxis - child |
123 |
122 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
36 |
25 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
354 |
348 |
$539.29 |
| D4341 |
|
24 |
19 |
$456.24 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
13 |
12 |
$431.28 |
| D1330 |
|
1,519 |
1,499 |
$128.00 |
| D0120 |
Periodic oral evaluation - established patient |
80 |
80 |
$74.00 |
| D0220 |
Intraoral - periapical first radiographic image |
152 |
150 |
$11.03 |
| D1206 |
Topical application of fluoride varnish |
125 |
124 |
$0.00 |
| D9995 |
|
262 |
261 |
$0.00 |