| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,043 |
995 |
$54K |
| D0274 |
Bitewings - four radiographic images |
1,004 |
976 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,268 |
1,223 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
758 |
716 |
$30K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
267 |
125 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,884 |
657 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
271 |
93 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,157 |
1,064 |
$14K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
53 |
26 |
$9K |
| D4910 |
|
57 |
55 |
$9K |
| D0330 |
Panoramic radiographic image |
131 |
124 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
389 |
372 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
135 |
127 |
$4K |
| D4342 |
|
49 |
13 |
$2K |
| D1120 |
Prophylaxis - child |
73 |
70 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
58 |
48 |
$669.04 |