| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,186 |
1,128 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
1,347 |
1,276 |
$26K |
| D1208 |
Topical application of fluoride, excluding varnish |
679 |
642 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
317 |
307 |
$12K |
| D0274 |
Bitewings - four radiographic images |
303 |
291 |
$11K |
| D1120 |
Prophylaxis - child |
186 |
176 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
34 |
12 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
33 |
26 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
56 |
39 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
55 |
54 |
$703.08 |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$627.69 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$330.00 |