| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,883 |
2,883 |
$140K |
| D0120 |
Periodic oral evaluation - established patient |
3,359 |
3,359 |
$73K |
| D0274 |
Bitewings - four radiographic images |
1,953 |
1,953 |
$52K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
541 |
385 |
$49K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,720 |
2,720 |
$43K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
332 |
245 |
$24K |
| D1120 |
Prophylaxis - child |
672 |
672 |
$23K |
| D0330 |
Panoramic radiographic image |
435 |
435 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
402 |
402 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
657 |
655 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
81 |
51 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
41 |
41 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
180 |
113 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
46 |
46 |
$2K |
| D0272 |
Bitewings - two radiographic images |
56 |
56 |
$1K |
| D1206 |
Topical application of fluoride varnish |
17 |
17 |
$323.00 |