| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,844 |
2,840 |
$99K |
| D0120 |
Periodic oral evaluation - established patient |
2,753 |
2,750 |
$55K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,338 |
3,335 |
$37K |
| D0220 |
Intraoral - periapical first radiographic image |
3,435 |
3,433 |
$32K |
| D0274 |
Bitewings - four radiographic images |
1,034 |
1,032 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
322 |
246 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
594 |
594 |
$12K |
| D1120 |
Prophylaxis - child |
285 |
285 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
506 |
506 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
842 |
839 |
$5K |
| D0330 |
Panoramic radiographic image |
72 |
72 |
$2K |
| D0272 |
Bitewings - two radiographic images |
101 |
101 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
15 |
13 |
$516.05 |
| D4999 |
|
37 |
32 |
$0.00 |
| D1999 |
|
36 |
31 |
$0.00 |