| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
6,056 |
6,033 |
$216K |
| D0120 |
Periodic oral evaluation - established patient |
8,054 |
7,990 |
$158K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,561 |
3,548 |
$70K |
| D5110 |
|
85 |
84 |
$40K |
| D7140 |
Extraction, erupted tooth or exposed root |
211 |
136 |
$14K |
| S0215 |
Non-emergency transportation; mileage, per mile |
1,362 |
1,346 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
82 |
82 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
46 |
45 |
$2K |
| D9110 |
|
45 |
44 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
13 |
$900.00 |
| D2331 |
|
14 |
13 |
$840.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
12 |
$736.00 |
| D2330 |
|
14 |
12 |
$700.00 |
| D9410 |
|
127 |
124 |
$0.00 |