| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
5,261 |
5,261 |
$203K |
| D0120 |
Periodic oral evaluation - established patient |
5,907 |
5,907 |
$124K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,389 |
5,383 |
$111K |
| D0220 |
Intraoral - periapical first radiographic image |
6,938 |
6,909 |
$88K |
| D1120 |
Prophylaxis - child |
2,193 |
2,193 |
$70K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,691 |
3,691 |
$41K |
| D0210 |
Intraoral - complete series of radiographic images |
4,375 |
4,366 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,539 |
1,539 |
$33K |
| D0272 |
Bitewings - two radiographic images |
1,922 |
1,922 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
561 |
467 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
218 |
190 |
$12K |
| D0274 |
Bitewings - four radiographic images |
263 |
263 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
198 |
198 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
14 |
12 |
$551.44 |