| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,168 |
1,999 |
$60K |
| D0120 |
Periodic oral evaluation - established patient |
2,227 |
2,052 |
$47K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,085 |
955 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
166 |
108 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
203 |
168 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
105 |
102 |
$4K |
| D1120 |
Prophylaxis - child |
128 |
127 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
49 |
26 |
$2K |
| D9410 |
|
16 |
13 |
$748.00 |
| D0220 |
Intraoral - periapical first radiographic image |
159 |
119 |
$526.60 |
| D1208 |
Topical application of fluoride, excluding varnish |
44 |
44 |
$464.00 |
| D0274 |
Bitewings - four radiographic images |
29 |
26 |
$402.00 |
| D1206 |
Topical application of fluoride varnish |
16 |
15 |
$270.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
34 |
12 |
$82.20 |
| D0170 |
|
62 |
61 |
$0.00 |