| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,254 |
2,254 |
$102K |
| D0120 |
Periodic oral evaluation - established patient |
3,049 |
3,045 |
$68K |
| D7140 |
Extraction, erupted tooth or exposed root |
662 |
441 |
$33K |
| D0330 |
Panoramic radiographic image |
1,044 |
1,044 |
$32K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,736 |
1,714 |
$31K |
| D0274 |
Bitewings - four radiographic images |
1,268 |
1,267 |
$28K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
482 |
302 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
712 |
712 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
922 |
919 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
545 |
545 |
$6K |
| D1120 |
Prophylaxis - child |
161 |
161 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
66 |
54 |
$5K |
| D4341 |
|
55 |
25 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
160 |
159 |
$2K |
| D9945 |
|
14 |
14 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
88 |
88 |
$732.43 |