| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,953 |
3,953 |
$212K |
| D0120 |
Periodic oral evaluation - established patient |
3,713 |
3,713 |
$101K |
| D0274 |
Bitewings - four radiographic images |
2,270 |
2,270 |
$59K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
345 |
255 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
777 |
777 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
261 |
208 |
$15K |
| D0330 |
Panoramic radiographic image |
467 |
467 |
$13K |
| D1120 |
Prophylaxis - child |
280 |
280 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
745 |
745 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
607 |
602 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
65 |
26 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
67 |
67 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
62 |
62 |
$835.03 |
| D0272 |
Bitewings - two radiographic images |
17 |
17 |
$273.02 |