| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,882 |
1,880 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
2,463 |
2,456 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
952 |
949 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
415 |
342 |
$20K |
| D0272 |
Bitewings - two radiographic images |
2,153 |
2,148 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
135 |
110 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
1,359 |
1,322 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
352 |
350 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
71 |
51 |
$4K |
| D0330 |
Panoramic radiographic image |
61 |
61 |
$3K |
| D1120 |
Prophylaxis - child |
105 |
104 |
$2K |
| D1206 |
Topical application of fluoride varnish |
116 |
116 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
30 |
30 |
$609.66 |
| D0230 |
Intraoral - periapical each additional radiographic image |
127 |
71 |
$570.00 |