| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,216 |
3,210 |
$116K |
| D0120 |
Periodic oral evaluation - established patient |
4,439 |
4,429 |
$91K |
| D0274 |
Bitewings - four radiographic images |
3,347 |
3,345 |
$65K |
| D0220 |
Intraoral - periapical first radiographic image |
4,250 |
4,238 |
$41K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
650 |
544 |
$39K |
| D1120 |
Prophylaxis - child |
897 |
897 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,924 |
3,921 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,950 |
1,948 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
191 |
159 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
260 |
260 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
75 |
74 |
$764.31 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
13 |
12 |
$683.20 |
| D0330 |
Panoramic radiographic image |
26 |
26 |
$642.55 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$212.00 |