| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
5,204 |
5,198 |
$196K |
| D0120 |
Periodic oral evaluation - established patient |
4,422 |
4,415 |
$90K |
| D0274 |
Bitewings - four radiographic images |
4,320 |
4,312 |
$83K |
| D0220 |
Intraoral - periapical first radiographic image |
5,584 |
5,434 |
$41K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,349 |
1,349 |
$31K |
| D0210 |
Intraoral - complete series of radiographic images |
780 |
764 |
$26K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,797 |
4,712 |
$22K |
| D1120 |
Prophylaxis - child |
435 |
435 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,228 |
1,226 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
209 |
155 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
466 |
458 |
$5K |
| D0330 |
Panoramic radiographic image |
138 |
138 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
45 |
24 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
51 |
38 |
$2K |
| D9110 |
|
51 |
51 |
$987.04 |
| D0601 |
|
13 |
13 |
$13.00 |
| D1330 |
|
20 |
20 |
$0.00 |
| D1999 |
|
42 |
39 |
$0.00 |