| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,568 |
2,553 |
$48K |
| D0120 |
Periodic oral evaluation - established patient |
1,955 |
1,941 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,174 |
1,167 |
$29K |
| D0210 |
Intraoral - complete series of radiographic images |
763 |
758 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,813 |
2,193 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
2,873 |
2,716 |
$11K |
| D0274 |
Bitewings - four radiographic images |
783 |
776 |
$7K |
| D1206 |
Topical application of fluoride varnish |
281 |
281 |
$4K |
| D1120 |
Prophylaxis - child |
194 |
194 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
72 |
25 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
51 |
37 |
$2K |
| D0272 |
Bitewings - two radiographic images |
120 |
120 |
$600.00 |
| D0140 |
Limited oral evaluation - problem focused |
28 |
27 |
$496.00 |
| D1330 |
|
12 |
12 |
$0.00 |