| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
5,030 |
5,023 |
$167K |
| D0120 |
Periodic oral evaluation - established patient |
5,373 |
5,359 |
$102K |
| D0274 |
Bitewings - four radiographic images |
4,974 |
4,965 |
$88K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,361 |
6,351 |
$54K |
| D0220 |
Intraoral - periapical first radiographic image |
5,386 |
5,378 |
$45K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
866 |
865 |
$18K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
261 |
151 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
237 |
166 |
$14K |
| D1120 |
Prophylaxis - child |
397 |
396 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
141 |
101 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
342 |
157 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
989 |
983 |
$10K |
| D0330 |
Panoramic radiographic image |
463 |
459 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
421 |
419 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
308 |
300 |
$3K |
| D9310 |
|
30 |
30 |
$693.67 |