| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,324 |
1,201 |
$55K |
| D0210 |
Intraoral - complete series of radiographic images |
881 |
804 |
$40K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
574 |
338 |
$37K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,134 |
1,025 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
1,265 |
1,146 |
$26K |
| D1206 |
Topical application of fluoride varnish |
1,480 |
1,315 |
$16K |
| D0274 |
Bitewings - four radiographic images |
380 |
338 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
297 |
262 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,002 |
885 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
91 |
27 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
691 |
285 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
35 |
27 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
22 |
12 |
$4K |
| D0330 |
Panoramic radiographic image |
69 |
67 |
$3K |
| D1120 |
Prophylaxis - child |
112 |
99 |
$2K |
| D4346 |
|
15 |
14 |
$2K |
| D1351 |
Sealant - per tooth |
98 |
12 |
$997.90 |
| D0431 |
|
57 |
55 |
$0.00 |