| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
763 |
748 |
$40K |
| D1110 |
Prophylaxis - adult |
463 |
451 |
$39K |
| D4910 |
|
262 |
257 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
888 |
860 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
851 |
834 |
$11K |
| D0272 |
Bitewings - two radiographic images |
675 |
661 |
$8K |
| D1320 |
|
219 |
216 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
12 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
17 |
12 |
$975.80 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
12 |
$168.00 |