| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,951 |
1,920 |
$102K |
| D0274 |
Bitewings - four radiographic images |
1,291 |
1,276 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
1,692 |
1,666 |
$38K |
| D0220 |
Intraoral - periapical first radiographic image |
2,113 |
2,057 |
$32K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,750 |
1,581 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
147 |
146 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
23 |
13 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
68 |
68 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
35 |
26 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
79 |
77 |
$2K |
| D1120 |
Prophylaxis - child |
39 |
39 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
24 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
12 |
$1K |