| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
768 |
695 |
$24K |
| D0210 |
Intraoral - complete series of radiographic images |
387 |
348 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
750 |
689 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
355 |
331 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
188 |
92 |
$13K |
| D1206 |
Topical application of fluoride varnish |
610 |
579 |
$12K |
| D1120 |
Prophylaxis - child |
298 |
268 |
$11K |
| D0274 |
Bitewings - four radiographic images |
367 |
352 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
285 |
254 |
$5K |
| D1351 |
Sealant - per tooth |
112 |
28 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
165 |
140 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
22 |
13 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
43 |
15 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
27 |
14 |
$2K |
| D0330 |
Panoramic radiographic image |
39 |
39 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
90 |
79 |
$808.00 |