| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,407 |
1,361 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
567 |
347 |
$11K |
| D0274 |
Bitewings - four radiographic images |
1,485 |
1,422 |
$7K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
166 |
88 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
932 |
893 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
677 |
648 |
$5K |
| D0330 |
Panoramic radiographic image |
548 |
525 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
308 |
298 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
631 |
595 |
$1K |
| D4355 |
|
53 |
52 |
$1K |
| D1120 |
Prophylaxis - child |
176 |
166 |
$1K |
| D1206 |
Topical application of fluoride varnish |
432 |
407 |
$1K |
| D1354 |
|
1,722 |
373 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$835.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
68 |
49 |
$656.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
31 |
26 |
$258.00 |
| D0603 |
|
48 |
43 |
$10.00 |
| D4265 |
|
15 |
12 |
$0.00 |
| D0601 |
|
157 |
146 |
$0.00 |
| D0602 |
|
75 |
73 |
$0.00 |