| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,289 |
1,266 |
$84K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
565 |
421 |
$76K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
919 |
895 |
$50K |
| D0330 |
Panoramic radiographic image |
874 |
850 |
$39K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
182 |
155 |
$31K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
273 |
177 |
$28K |
| D0274 |
Bitewings - four radiographic images |
1,012 |
989 |
$24K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
198 |
98 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
476 |
476 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,110 |
1,081 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,227 |
1,191 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
233 |
227 |
$11K |
| D1206 |
Topical application of fluoride varnish |
24 |
24 |
$630.96 |