| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
677 |
545 |
$21K |
| D0999 |
Unspecified diagnostic procedure, by report |
171 |
142 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
1,307 |
950 |
$14K |
| D1120 |
Prophylaxis - child |
502 |
326 |
$6K |
| D1206 |
Topical application of fluoride varnish |
811 |
546 |
$5K |
| D0274 |
Bitewings - four radiographic images |
197 |
158 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
13 |
$3K |
| T1015 |
Clinic visit/encounter, all-inclusive |
645 |
450 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
12 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
17 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
36 |
25 |
$884.40 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
13 |
12 |
$572.00 |
| D0210 |
Intraoral - complete series of radiographic images |
22 |
12 |
$0.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
105 |
98 |
$0.00 |