| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,069 |
3,068 |
$179K |
| D0120 |
Periodic oral evaluation - established patient |
5,216 |
5,212 |
$151K |
| D1120 |
Prophylaxis - child |
1,581 |
1,579 |
$69K |
| D0274 |
Bitewings - four radiographic images |
2,187 |
2,185 |
$63K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,283 |
2,280 |
$33K |
| D0210 |
Intraoral - complete series of radiographic images |
297 |
293 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
115 |
95 |
$12K |
| D2750 |
|
16 |
12 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
726 |
720 |
$10K |
| D0272 |
Bitewings - two radiographic images |
167 |
167 |
$3K |
| D0330 |
Panoramic radiographic image |
60 |
60 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
27 |
27 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
69 |
69 |
$781.83 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$459.55 |
| D9110 |
|
12 |
12 |
$348.00 |