| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,480 |
2,479 |
$62K |
| D0120 |
Periodic oral evaluation - established patient |
3,773 |
3,762 |
$52K |
| D0274 |
Bitewings - four radiographic images |
2,688 |
2,687 |
$35K |
| D0330 |
Panoramic radiographic image |
1,269 |
1,265 |
$15K |
| D1120 |
Prophylaxis - child |
758 |
756 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
604 |
602 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
234 |
234 |
$4K |
| D0272 |
Bitewings - two radiographic images |
372 |
372 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
82 |
72 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
242 |
239 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
203 |
202 |
$2K |
| D1999 |
|
29 |
29 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
28 |
26 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
35 |
35 |
$555.72 |
| D1206 |
Topical application of fluoride varnish |
40 |
40 |
$548.84 |
| D0230 |
Intraoral - periapical each additional radiographic image |
28 |
28 |
$106.78 |