| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
6,136 |
6,133 |
$213K |
| D0120 |
Periodic oral evaluation - established patient |
8,061 |
8,056 |
$160K |
| D0274 |
Bitewings - four radiographic images |
5,045 |
5,044 |
$94K |
| D0220 |
Intraoral - periapical first radiographic image |
7,910 |
7,898 |
$71K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,319 |
8,304 |
$70K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
334 |
250 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
452 |
332 |
$18K |
| D1120 |
Prophylaxis - child |
495 |
494 |
$15K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
229 |
138 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
795 |
795 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
552 |
552 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
566 |
563 |
$6K |
| D9990 |
|
254 |
247 |
$5K |
| D2394 |
|
29 |
26 |
$2K |
| D0330 |
Panoramic radiographic image |
46 |
46 |
$1K |
| D1320 |
|
99 |
99 |
$784.00 |
| D1999 |
|
15 |
15 |
$750.00 |
| D9310 |
|
18 |
18 |
$617.16 |
| D0270 |
|
27 |
27 |
$228.60 |