| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,805 |
1,790 |
$65K |
| D0120 |
Periodic oral evaluation - established patient |
2,033 |
2,015 |
$48K |
| D7140 |
Extraction, erupted tooth or exposed root |
398 |
114 |
$30K |
| D0330 |
Panoramic radiographic image |
1,169 |
1,158 |
$30K |
| D1999 |
|
2,442 |
2,230 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
689 |
686 |
$17K |
| D1120 |
Prophylaxis - child |
548 |
548 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
178 |
178 |
$8K |
| D0274 |
Bitewings - four radiographic images |
683 |
680 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
215 |
212 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
15 |
$1K |
| D1206 |
Topical application of fluoride varnish |
17 |
17 |
$320.00 |
| D0272 |
Bitewings - two radiographic images |
24 |
24 |
$147.21 |