| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,241 |
4,239 |
$117K |
| D0120 |
Periodic oral evaluation - established patient |
5,140 |
5,139 |
$76K |
| D0274 |
Bitewings - four radiographic images |
2,540 |
2,540 |
$43K |
| D0220 |
Intraoral - periapical first radiographic image |
4,559 |
4,509 |
$35K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,680 |
3,573 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
399 |
226 |
$15K |
| D1120 |
Prophylaxis - child |
468 |
468 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,364 |
1,364 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
262 |
178 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
849 |
838 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
12 |
$973.45 |
| D0272 |
Bitewings - two radiographic images |
201 |
201 |
$876.32 |
| D7510 |
|
12 |
12 |
$552.58 |
| D0210 |
Intraoral - complete series of radiographic images |
41 |
41 |
$545.31 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$143.24 |