| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,421 |
1,248 |
$66K |
| D0120 |
Periodic oral evaluation - established patient |
1,671 |
1,394 |
$44K |
| D0272 |
Bitewings - two radiographic images |
1,491 |
1,263 |
$33K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,271 |
1,028 |
$25K |
| D1120 |
Prophylaxis - child |
272 |
187 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
100 |
75 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
105 |
41 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
156 |
156 |
$5K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
31 |
15 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
67 |
49 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
95 |
79 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
12 |
$2K |
| D0603 |
|
198 |
117 |
$990.00 |
| D1206 |
Topical application of fluoride varnish |
15 |
14 |
$263.09 |
| D0602 |
|
35 |
18 |
$175.00 |