| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,000 |
995 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
943 |
936 |
$19K |
| D0274 |
Bitewings - four radiographic images |
389 |
388 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
253 |
252 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
102 |
63 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
59 |
49 |
$3K |
| D1120 |
Prophylaxis - child |
102 |
102 |
$3K |
| D9110 |
|
104 |
100 |
$3K |
| D1206 |
Topical application of fluoride varnish |
155 |
153 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
227 |
221 |
$2K |
| D0272 |
Bitewings - two radiographic images |
89 |
89 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
20 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
18 |
18 |
$647.45 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
13 |
$256.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$242.64 |