| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
740 |
735 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
686 |
680 |
$17K |
| D0274 |
Bitewings - four radiographic images |
742 |
738 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
405 |
190 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
790 |
784 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
302 |
150 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
22 |
14 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
140 |
136 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
39 |
25 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
1,023 |
1,011 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
683 |
679 |
$847.55 |
| D1208 |
Topical application of fluoride, excluding varnish |
141 |
140 |
$539.85 |
| D1999 |
|
19 |
18 |
$399.20 |
| D0330 |
Panoramic radiographic image |
73 |
71 |
$329.43 |
| D0230 |
Intraoral - periapical each additional radiographic image |
881 |
873 |
$312.89 |
| D1330 |
|
158 |
155 |
$74.16 |