| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
393 |
373 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
224 |
204 |
$3K |
| D1206 |
Topical application of fluoride varnish |
270 |
244 |
$2K |
| D0330 |
Panoramic radiographic image |
148 |
134 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
157 |
144 |
$2K |
| D0274 |
Bitewings - four radiographic images |
126 |
118 |
$1K |
| D1120 |
Prophylaxis - child |
38 |
32 |
$449.70 |
| D0220 |
Intraoral - periapical first radiographic image |
148 |
142 |
$35.00 |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$0.00 |
| D1330 |
|
154 |
153 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
94 |
86 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
12 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
29 |
15 |
$0.00 |