| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,946 |
4,944 |
$185K |
| D0274 |
Bitewings - four radiographic images |
5,478 |
5,475 |
$104K |
| D0120 |
Periodic oral evaluation - established patient |
4,073 |
4,070 |
$84K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,486 |
2,483 |
$57K |
| D0220 |
Intraoral - periapical first radiographic image |
7,045 |
7,026 |
$55K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,636 |
6,624 |
$47K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
554 |
271 |
$35K |
| D1120 |
Prophylaxis - child |
648 |
647 |
$21K |
| D0330 |
Panoramic radiographic image |
925 |
924 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
2,038 |
2,031 |
$18K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
164 |
84 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,083 |
1,082 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
183 |
114 |
$13K |
| D2750 |
|
15 |
14 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
304 |
301 |
$3K |
| D0272 |
Bitewings - two radiographic images |
58 |
58 |
$695.58 |
| D9110 |
|
29 |
29 |
$407.16 |
| D1310 |
|
33 |
33 |
$0.00 |