| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
6,800 |
6,792 |
$243K |
| D2750 |
|
634 |
466 |
$213K |
| D0120 |
Periodic oral evaluation - established patient |
6,323 |
6,309 |
$130K |
| D0274 |
Bitewings - four radiographic images |
5,281 |
5,278 |
$107K |
| D0210 |
Intraoral - complete series of radiographic images |
3,049 |
3,039 |
$91K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,156 |
3,156 |
$72K |
| D0220 |
Intraoral - periapical first radiographic image |
6,959 |
6,938 |
$60K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
808 |
604 |
$45K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,791 |
6,749 |
$45K |
| D2954 |
|
327 |
302 |
$36K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
910 |
664 |
$34K |
| D1120 |
Prophylaxis - child |
802 |
802 |
$32K |
| D6010 |
|
28 |
12 |
$28K |
| D2932 |
|
164 |
149 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
894 |
892 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
523 |
518 |
$5K |
| D3320 |
|
27 |
26 |
$5K |
| D0272 |
Bitewings - two radiographic images |
346 |
346 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
51 |
50 |
$3K |
| D4341 |
|
28 |
12 |
$1K |