| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,268 |
2,260 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
3,390 |
3,374 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
938 |
642 |
$23K |
| D0274 |
Bitewings - four radiographic images |
2,125 |
2,118 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
249 |
249 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
83 |
58 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,416 |
1,411 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
648 |
432 |
$4K |
| D1120 |
Prophylaxis - child |
846 |
845 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
1,616 |
1,607 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,144 |
1,143 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
681 |
674 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
39 |
24 |
$1K |
| D0272 |
Bitewings - two radiographic images |
422 |
420 |
$664.97 |
| D0160 |
|
25 |
25 |
$570.00 |
| D0330 |
Panoramic radiographic image |
15 |
14 |
$487.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
13 |
$448.38 |
| D1330 |
|
1,051 |
1,046 |
$0.00 |