| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,454 |
1,454 |
$100K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,113 |
641 |
$99K |
| D0140 |
Limited oral evaluation - problem focused |
1,768 |
1,685 |
$79K |
| D0330 |
Panoramic radiographic image |
982 |
982 |
$67K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
745 |
745 |
$52K |
| D0220 |
Intraoral - periapical first radiographic image |
2,891 |
2,619 |
$48K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
291 |
204 |
$44K |
| D0274 |
Bitewings - four radiographic images |
909 |
907 |
$36K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,408 |
1,408 |
$34K |
| D0460 |
|
945 |
877 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
679 |
679 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,449 |
1,364 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
62 |
40 |
$9K |
| D2750 |
|
16 |
12 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
63 |
43 |
$7K |
| D1120 |
Prophylaxis - child |
113 |
113 |
$5K |
| D1206 |
Topical application of fluoride varnish |
124 |
124 |
$4K |
| D9430 |
|
43 |
43 |
$2K |
| D0431 |
|
1,408 |
1,402 |
$0.00 |
| D2950 |
|
17 |
14 |
$0.00 |