| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,030 |
2,029 |
$134K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,552 |
1,128 |
$131K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
668 |
541 |
$65K |
| D0120 |
Periodic oral evaluation - established patient |
1,612 |
1,612 |
$53K |
| D0140 |
Limited oral evaluation - problem focused |
2,257 |
2,249 |
$40K |
| D0274 |
Bitewings - four radiographic images |
1,054 |
1,054 |
$36K |
| D0220 |
Intraoral - periapical first radiographic image |
2,056 |
2,030 |
$34K |
| D0210 |
Intraoral - complete series of radiographic images |
492 |
492 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
901 |
901 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
447 |
336 |
$29K |
| D0330 |
Panoramic radiographic image |
253 |
253 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
80 |
75 |
$10K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
57 |
55 |
$9K |
| D1120 |
Prophylaxis - child |
179 |
179 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
317 |
317 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
248 |
248 |
$4K |
| D1206 |
Topical application of fluoride varnish |
128 |
128 |
$4K |
| D9991 |
|
110 |
109 |
$0.00 |
| D9995 |
|
309 |
306 |
$0.00 |