| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
481 |
462 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
582 |
565 |
$10K |
| D0330 |
Panoramic radiographic image |
209 |
201 |
$9K |
| D0274 |
Bitewings - four radiographic images |
348 |
339 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
241 |
228 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
352 |
344 |
$6K |
| D1120 |
Prophylaxis - child |
191 |
187 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
763 |
451 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
629 |
605 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
157 |
150 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
59 |
45 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
70 |
31 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
51 |
30 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
39 |
39 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
34 |
27 |
$2K |
| D1320 |
|
59 |
57 |
$765.00 |
| D0272 |
Bitewings - two radiographic images |
29 |
29 |
$425.10 |
| D1206 |
Topical application of fluoride varnish |
19 |
19 |
$270.00 |