| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
448 |
445 |
$39K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
584 |
582 |
$39K |
| D0210 |
Intraoral - complete series of radiographic images |
332 |
332 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
486 |
483 |
$7K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
43 |
29 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
36 |
35 |
$3K |
| D0274 |
Bitewings - four radiographic images |
136 |
134 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
277 |
195 |
$3K |
| D0330 |
Panoramic radiographic image |
66 |
66 |
$2K |
| D9430 |
|
47 |
44 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
12 |
$1K |
| D0350 |
|
14 |
14 |
$284.20 |