| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,626 |
2,626 |
$97K |
| D0120 |
Periodic oral evaluation - established patient |
2,085 |
2,085 |
$40K |
| D0274 |
Bitewings - four radiographic images |
884 |
884 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,750 |
1,725 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
656 |
656 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
166 |
121 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
204 |
202 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,112 |
1,109 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
65 |
51 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
210 |
200 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
13 |
12 |
$1K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
20 |
15 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
56 |
56 |
$612.25 |
| D1120 |
Prophylaxis - child |
17 |
17 |
$414.56 |
| D0330 |
Panoramic radiographic image |
22 |
22 |
$149.61 |