| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,710 |
1,707 |
$57K |
| D0120 |
Periodic oral evaluation - established patient |
1,506 |
1,503 |
$30K |
| D0274 |
Bitewings - four radiographic images |
1,455 |
1,453 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
1,907 |
1,892 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
277 |
277 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,732 |
1,725 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
374 |
374 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
65 |
39 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
25 |
13 |
$764.70 |
| D1120 |
Prophylaxis - child |
24 |
24 |
$693.08 |
| D1208 |
Topical application of fluoride, excluding varnish |
43 |
43 |
$460.40 |
| D0140 |
Limited oral evaluation - problem focused |
25 |
25 |
$253.44 |
| D1999 |
|
31 |
29 |
$0.00 |