| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,830 |
2,823 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
2,732 |
2,725 |
$43K |
| D0330 |
Panoramic radiographic image |
1,666 |
1,663 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,380 |
1,378 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,637 |
2,339 |
$16K |
| D0274 |
Bitewings - four radiographic images |
1,963 |
1,959 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
800 |
778 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
477 |
263 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
2,831 |
2,785 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
228 |
136 |
$8K |
| D4341 |
|
219 |
94 |
$7K |
| D1120 |
Prophylaxis - child |
300 |
300 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
165 |
165 |
$4K |
| D4355 |
|
73 |
73 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
157 |
157 |
$1K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
15 |
12 |
$885.50 |
| D9210 |
|
78 |
70 |
$713.40 |
| D9310 |
|
73 |
73 |
$418.00 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$100.50 |