| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
954 |
942 |
$52K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
447 |
179 |
$47K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,169 |
1,157 |
$27K |
| D2750 |
|
60 |
39 |
$26K |
| D9110 |
|
423 |
419 |
$23K |
| D0330 |
Panoramic radiographic image |
324 |
321 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
350 |
349 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,187 |
1,116 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
590 |
580 |
$14K |
| D0274 |
Bitewings - four radiographic images |
398 |
396 |
$12K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
85 |
56 |
$10K |
| D4341 |
|
84 |
25 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
843 |
771 |
$8K |
| D2799 |
|
15 |
12 |
$3K |
| D2954 |
|
26 |
18 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
14 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
29 |
28 |
$1K |
| D0460 |
|
57 |
55 |
$1K |
| D1120 |
Prophylaxis - child |
14 |
14 |
$511.03 |