| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,277 |
1,277 |
$63K |
| D0120 |
Periodic oral evaluation - established patient |
1,709 |
1,709 |
$38K |
| D1208 |
Topical application of fluoride, excluding varnish |
947 |
947 |
$15K |
| D0274 |
Bitewings - four radiographic images |
522 |
522 |
$14K |
| D0272 |
Bitewings - two radiographic images |
413 |
413 |
$8K |
| D1206 |
Topical application of fluoride varnish |
381 |
381 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
164 |
164 |
$6K |
| D1120 |
Prophylaxis - child |
124 |
124 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
38 |
27 |
$4K |
| D0330 |
Panoramic radiographic image |
65 |
65 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
187 |
185 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
24 |
13 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
25 |
25 |
$948.69 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$117.92 |