| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
629 |
621 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
583 |
574 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
208 |
110 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
589 |
558 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
222 |
73 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,199 |
1,098 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
195 |
194 |
$11K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
170 |
60 |
$10K |
| D1206 |
Topical application of fluoride varnish |
278 |
278 |
$7K |
| D0274 |
Bitewings - four radiographic images |
419 |
411 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
999 |
777 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
103 |
103 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
25 |
25 |
$869.83 |
| D0330 |
Panoramic radiographic image |
29 |
28 |
$801.78 |