| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,641 |
2,605 |
$72K |
| D0330 |
Panoramic radiographic image |
1,292 |
1,277 |
$66K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
811 |
506 |
$32K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,302 |
687 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
2,434 |
2,401 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,494 |
1,477 |
$20K |
| D1120 |
Prophylaxis - child |
972 |
963 |
$12K |
| D1330 |
|
2,374 |
2,346 |
$5K |
| D0272 |
Bitewings - two radiographic images |
1,927 |
1,902 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,369 |
2,342 |
$2K |
| D1351 |
Sealant - per tooth |
229 |
61 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
1,513 |
1,493 |
$961.87 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
22 |
12 |
$938.59 |
| D0274 |
Bitewings - four radiographic images |
18 |
18 |
$820.24 |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,300 |
1,256 |
$584.34 |
| D0140 |
Limited oral evaluation - problem focused |
28 |
27 |
$226.89 |
| D3120 |
|
43 |
29 |
$23.26 |
| D0601 |
|
1,797 |
1,771 |
$0.00 |
| D0210 |
Intraoral - complete series of radiographic images |
57 |
57 |
$0.00 |