| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,174 |
1,153 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
1,310 |
1,288 |
$31K |
| D0220 |
Intraoral - periapical first radiographic image |
1,894 |
1,805 |
$27K |
| D0140 |
Limited oral evaluation - problem focused |
727 |
696 |
$25K |
| D0274 |
Bitewings - four radiographic images |
572 |
556 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
893 |
774 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
80 |
51 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
76 |
32 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
111 |
106 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
46 |
28 |
$3K |
| D0330 |
Panoramic radiographic image |
42 |
41 |
$2K |
| D1206 |
Topical application of fluoride varnish |
120 |
120 |
$2K |
| D4355 |
|
12 |
12 |
$765.48 |