| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,751 |
2,745 |
$68K |
| D0120 |
Periodic oral evaluation - established patient |
3,140 |
3,135 |
$41K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
707 |
221 |
$37K |
| D0274 |
Bitewings - four radiographic images |
2,558 |
2,552 |
$32K |
| D0220 |
Intraoral - periapical first radiographic image |
3,752 |
3,707 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,735 |
1,600 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
400 |
399 |
$11K |
| D1120 |
Prophylaxis - child |
453 |
452 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
582 |
582 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
194 |
94 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
62 |
26 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
520 |
519 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
477 |
470 |
$3K |
| D1999 |
|
13 |
13 |
$650.00 |