| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
522 |
512 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,042 |
1,022 |
$20K |
| D1120 |
Prophylaxis - child |
605 |
597 |
$19K |
| D1110 |
Prophylaxis - adult |
416 |
413 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
258 |
119 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
661 |
652 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
435 |
431 |
$13K |
| D9110 |
|
193 |
190 |
$9K |
| D1351 |
Sealant - per tooth |
478 |
107 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
349 |
340 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
75 |
58 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
49 |
41 |
$4K |
| D0330 |
Panoramic radiographic image |
73 |
73 |
$3K |
| D0272 |
Bitewings - two radiographic images |
63 |
63 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
42 |
40 |
$947.58 |
| D0274 |
Bitewings - four radiographic images |
24 |
24 |
$595.33 |
| D0230 |
Intraoral - periapical each additional radiographic image |
16 |
12 |
$101.38 |
| D1330 |
|
16 |
15 |
$0.00 |