| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,316 |
1,310 |
$55K |
| D0140 |
Limited oral evaluation - problem focused |
755 |
697 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
1,181 |
1,175 |
$27K |
| D0274 |
Bitewings - four radiographic images |
617 |
615 |
$20K |
| D7140 |
Extraction, erupted tooth or exposed root |
247 |
64 |
$19K |
| D1330 |
|
1,299 |
1,299 |
$17K |
| D1310 |
|
1,302 |
1,302 |
$17K |
| D9920 |
|
93 |
86 |
$12K |
| D0330 |
Panoramic radiographic image |
123 |
123 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
176 |
176 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
72 |
72 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
13 |
$2K |
| D1120 |
Prophylaxis - child |
43 |
43 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
89 |
87 |
$846.40 |