| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,446 |
1,300 |
$52K |
| D0274 |
Bitewings - four radiographic images |
1,187 |
1,049 |
$24K |
| D0330 |
Panoramic radiographic image |
651 |
564 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
346 |
210 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
769 |
728 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
712 |
604 |
$15K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
227 |
90 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
454 |
405 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
92 |
45 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
591 |
517 |
$4K |
| D1206 |
Topical application of fluoride varnish |
204 |
189 |
$3K |
| D1120 |
Prophylaxis - child |
41 |
40 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
16 |
14 |
$96.75 |