| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,362 |
1,335 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
1,421 |
1,390 |
$33K |
| D4355 |
|
456 |
446 |
$29K |
| D7140 |
Extraction, erupted tooth or exposed root |
452 |
128 |
$26K |
| D0170 |
|
724 |
673 |
$19K |
| D9420 |
|
131 |
114 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
844 |
805 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
280 |
270 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,161 |
583 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
118 |
79 |
$11K |
| D0274 |
Bitewings - four radiographic images |
350 |
342 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
76 |
51 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
148 |
141 |
$2K |
| D0330 |
Panoramic radiographic image |
35 |
35 |
$2K |
| D0160 |
|
24 |
24 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
24 |
$2K |
| D2331 |
|
20 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
18 |
16 |
$607.92 |
| D1120 |
Prophylaxis - child |
14 |
12 |
$284.57 |