| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
986 |
985 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
1,428 |
1,424 |
$38K |
| D1206 |
Topical application of fluoride varnish |
1,528 |
1,524 |
$28K |
| D0274 |
Bitewings - four radiographic images |
533 |
532 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,171 |
1,130 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
306 |
290 |
$10K |
| D4910 |
|
141 |
141 |
$9K |
| D1120 |
Prophylaxis - child |
242 |
240 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
139 |
97 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
133 |
80 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
773 |
695 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
132 |
132 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
52 |
52 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
32 |
12 |
$2K |
| D1999 |
|
266 |
246 |
$917.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
32 |
32 |
$572.00 |
| D0601 |
|
40 |
40 |
$385.00 |
| D0602 |
|
34 |
34 |
$352.00 |
| D0603 |
|
30 |
30 |
$297.00 |
| D1330 |
|
154 |
154 |
$210.00 |