| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,411 |
1,992 |
$102K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,438 |
729 |
$84K |
| D0120 |
Periodic oral evaluation - established patient |
1,800 |
1,546 |
$43K |
| D0210 |
Intraoral - complete series of radiographic images |
626 |
557 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
709 |
620 |
$30K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
183 |
143 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,228 |
990 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
412 |
412 |
$8K |
| D0272 |
Bitewings - two radiographic images |
313 |
304 |
$6K |
| D1120 |
Prophylaxis - child |
181 |
180 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
340 |
274 |
$5K |
| D0274 |
Bitewings - four radiographic images |
111 |
74 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
13 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
18 |
12 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
13 |
$852.72 |
| D0230 |
Intraoral - periapical each additional radiographic image |
24 |
12 |
$135.86 |