| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
5,579 |
5,578 |
$194K |
| D0120 |
Periodic oral evaluation - established patient |
5,503 |
5,501 |
$112K |
| D0274 |
Bitewings - four radiographic images |
4,415 |
4,414 |
$85K |
| D0220 |
Intraoral - periapical first radiographic image |
5,855 |
5,834 |
$55K |
| D0210 |
Intraoral - complete series of radiographic images |
1,215 |
1,213 |
$40K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,992 |
4,985 |
$26K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,725 |
1,725 |
$19K |
| D1120 |
Prophylaxis - child |
220 |
220 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
236 |
236 |
$5K |
| D2750 |
|
15 |
12 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
109 |
89 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
89 |
56 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
24 |
24 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
105 |
105 |
$1K |
| D0431 |
|
154 |
154 |
$0.00 |
| D1999 |
|
89 |
78 |
$0.00 |