| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
10,175 |
10,170 |
$448K |
| D0120 |
Periodic oral evaluation - established patient |
11,239 |
11,231 |
$251K |
| D0274 |
Bitewings - four radiographic images |
5,976 |
5,975 |
$129K |
| D0220 |
Intraoral - periapical first radiographic image |
8,512 |
8,488 |
$90K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,334 |
7,317 |
$77K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
802 |
720 |
$58K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
369 |
318 |
$28K |
| D0210 |
Intraoral - complete series of radiographic images |
992 |
988 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,395 |
2,392 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
328 |
274 |
$15K |
| D1120 |
Prophylaxis - child |
409 |
409 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
725 |
719 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
324 |
324 |
$8K |
| D7240 |
Removal of impacted tooth - completely bony |
28 |
25 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
25 |
24 |
$2K |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$723.12 |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$325.45 |
| D1330 |
|
103 |
103 |
$0.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
1,468 |
1,393 |
$0.00 |
| D1999 |
|
1,474 |
1,398 |
$0.00 |