| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
661 |
659 |
$43K |
| D1208 |
Topical application of fluoride, excluding varnish |
973 |
969 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
740 |
731 |
$22K |
| D0274 |
Bitewings - four radiographic images |
788 |
784 |
$19K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
158 |
101 |
$18K |
| D0330 |
Panoramic radiographic image |
365 |
362 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
253 |
251 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
286 |
280 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
72 |
53 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
427 |
408 |
$5K |
| D1120 |
Prophylaxis - child |
56 |
56 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
27 |
27 |
$405.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
33 |
33 |
$341.12 |
| D1330 |
|
13 |
13 |
$78.00 |