| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,254 |
1,148 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
1,528 |
1,435 |
$37K |
| D0220 |
Intraoral - periapical first radiographic image |
2,138 |
1,877 |
$30K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
310 |
185 |
$30K |
| D0274 |
Bitewings - four radiographic images |
974 |
873 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
640 |
542 |
$24K |
| D0140 |
Limited oral evaluation - problem focused |
747 |
657 |
$24K |
| D1206 |
Topical application of fluoride varnish |
1,417 |
1,270 |
$21K |
| D0330 |
Panoramic radiographic image |
331 |
281 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,402 |
1,154 |
$16K |
| D1120 |
Prophylaxis - child |
412 |
378 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
85 |
49 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
99 |
24 |
$3K |
| D0272 |
Bitewings - two radiographic images |
42 |
38 |
$709.68 |
| D1999 |
|
1,868 |
1,426 |
$0.00 |