| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,167 |
1,164 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
821 |
820 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
653 |
653 |
$15K |
| D2752 |
|
44 |
36 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
639 |
631 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
821 |
820 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
366 |
256 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
192 |
123 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
92 |
53 |
$2K |
| D0330 |
Panoramic radiographic image |
97 |
97 |
$2K |
| D0274 |
Bitewings - four radiographic images |
199 |
199 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
446 |
441 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
110 |
110 |
$1K |
| D1120 |
Prophylaxis - child |
80 |
80 |
$843.75 |
| D2954 |
|
18 |
13 |
$831.25 |
| D7140 |
Extraction, erupted tooth or exposed root |
25 |
14 |
$687.50 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
63 |
56 |
$670.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$137.50 |
| D0230 |
Intraoral - periapical each additional radiographic image |
49 |
42 |
$111.50 |