| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,610 |
4,607 |
$155K |
| D0120 |
Periodic oral evaluation - established patient |
6,565 |
6,539 |
$120K |
| D0210 |
Intraoral - complete series of radiographic images |
1,055 |
1,053 |
$37K |
| D1120 |
Prophylaxis - child |
1,226 |
1,226 |
$34K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,269 |
2,269 |
$23K |
| D2750 |
|
28 |
15 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
701 |
692 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
88 |
63 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
42 |
26 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
221 |
215 |
$1K |
| D2954 |
|
12 |
12 |
$982.78 |
| D0140 |
Limited oral evaluation - problem focused |
79 |
79 |
$682.15 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$243.60 |