| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,774 |
2,768 |
$134K |
| D0120 |
Periodic oral evaluation - established patient |
2,267 |
2,258 |
$59K |
| D0274 |
Bitewings - four radiographic images |
2,219 |
2,216 |
$55K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
356 |
180 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
788 |
788 |
$23K |
| D0210 |
Intraoral - complete series of radiographic images |
389 |
389 |
$19K |
| D0330 |
Panoramic radiographic image |
295 |
295 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
200 |
123 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
137 |
115 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
355 |
355 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
293 |
291 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
41 |
13 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
15 |
$1K |
| D1120 |
Prophylaxis - child |
24 |
24 |
$996.65 |
| D0230 |
Intraoral - periapical each additional radiographic image |
103 |
90 |
$775.60 |