| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,183 |
1,178 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
1,061 |
1,056 |
$22K |
| D0274 |
Bitewings - four radiographic images |
567 |
557 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
155 |
97 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
1,267 |
1,225 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
193 |
193 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
91 |
58 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
61 |
30 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,380 |
901 |
$3K |
| D1120 |
Prophylaxis - child |
73 |
73 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
52 |
52 |
$2K |
| D9310 |
|
66 |
64 |
$1K |
| D0330 |
Panoramic radiographic image |
31 |
30 |
$605.00 |
| D0140 |
Limited oral evaluation - problem focused |
25 |
25 |
$528.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
35 |
35 |
$367.50 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$88.20 |