| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,155 |
1,150 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
1,221 |
1,213 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
562 |
559 |
$21K |
| D7140 |
Extraction, erupted tooth or exposed root |
169 |
67 |
$17K |
| D0274 |
Bitewings - four radiographic images |
517 |
514 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
140 |
139 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
296 |
293 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
83 |
37 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
676 |
662 |
$8K |
| D4910 |
|
102 |
100 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
215 |
213 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
14 |
$3K |
| D1206 |
Topical application of fluoride varnish |
94 |
92 |
$2K |
| D0180 |
|
30 |
30 |
$1K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$597.36 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$426.87 |