| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,213 |
2,202 |
$176K |
| D4341 |
|
5,481 |
1,431 |
$155K |
| D0120 |
Periodic oral evaluation - established patient |
1,716 |
1,707 |
$89K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,889 |
1,498 |
$55K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
663 |
663 |
$37K |
| D0220 |
Intraoral - periapical first radiographic image |
1,510 |
1,505 |
$17K |
| D1206 |
Topical application of fluoride varnish |
293 |
293 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
92 |
41 |
$5K |
| D0160 |
|
98 |
98 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
39 |
39 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
12 |
$819.00 |