| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
436 |
434 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
610 |
607 |
$17K |
| D1120 |
Prophylaxis - child |
331 |
329 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
398 |
396 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
188 |
166 |
$10K |
| D9110 |
|
180 |
166 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
135 |
118 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
457 |
415 |
$9K |
| D0274 |
Bitewings - four radiographic images |
434 |
433 |
$8K |
| D1206 |
Topical application of fluoride varnish |
271 |
269 |
$7K |
| D4341 |
|
35 |
16 |
$7K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
72 |
63 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
219 |
218 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
752 |
713 |
$5K |
| D0330 |
Panoramic radiographic image |
183 |
179 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
486 |
453 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
14 |
12 |
$873.95 |