| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,201 |
1,159 |
$45K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
435 |
280 |
$37K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
318 |
164 |
$21K |
| D0274 |
Bitewings - four radiographic images |
1,112 |
1,075 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
613 |
559 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
635 |
608 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
870 |
837 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,639 |
1,570 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
132 |
77 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,225 |
1,167 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
358 |
335 |
$6K |
| D0330 |
Panoramic radiographic image |
135 |
123 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
71 |
39 |
$3K |