| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,003 |
2,003 |
$112K |
| D2394 |
|
432 |
418 |
$78K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
534 |
511 |
$76K |
| D0120 |
Periodic oral evaluation - established patient |
1,728 |
1,728 |
$49K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
355 |
343 |
$49K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
410 |
395 |
$46K |
| D7140 |
Extraction, erupted tooth or exposed root |
142 |
139 |
$23K |
| D0330 |
Panoramic radiographic image |
623 |
623 |
$23K |
| D0274 |
Bitewings - four radiographic images |
819 |
819 |
$22K |
| D2335 |
|
69 |
66 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
464 |
464 |
$14K |
| D1120 |
Prophylaxis - child |
300 |
300 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
442 |
442 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
373 |
373 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
227 |
224 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
71 |
71 |
$924.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
59 |
54 |
$798.80 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
12 |
$770.00 |