| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,066 |
929 |
$63K |
| D0120 |
Periodic oral evaluation - established patient |
855 |
746 |
$23K |
| D0330 |
Panoramic radiographic image |
378 |
343 |
$22K |
| D0274 |
Bitewings - four radiographic images |
431 |
401 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
218 |
192 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
100 |
67 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
776 |
643 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
183 |
175 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
75 |
39 |
$6K |
| D7250 |
|
37 |
12 |
$5K |
| D1206 |
Topical application of fluoride varnish |
116 |
107 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
13 |
$2K |
| D2954 |
|
17 |
13 |
$1K |
| D0460 |
|
43 |
39 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
74 |
55 |
$842.40 |
| D9110 |
|
17 |
12 |
$810.50 |
| D1208 |
Topical application of fluoride, excluding varnish |
17 |
17 |
$416.70 |
| D1330 |
|
256 |
175 |
$36.00 |
| D0999 |
Unspecified diagnostic procedure, by report |
12 |
12 |
$0.00 |
| D0431 |
|
12 |
12 |
$0.00 |