| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,376 |
1,902 |
$84K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
351 |
89 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
2,573 |
2,060 |
$44K |
| D0274 |
Bitewings - four radiographic images |
1,298 |
1,029 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
986 |
811 |
$25K |
| D0140 |
Limited oral evaluation - problem focused |
738 |
620 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,814 |
1,461 |
$23K |
| D1120 |
Prophylaxis - child |
814 |
675 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
220 |
183 |
$15K |
| D0330 |
Panoramic radiographic image |
188 |
153 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
466 |
362 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
150 |
80 |
$3K |
| D4355 |
|
31 |
25 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
44 |
27 |
$2K |
| D0272 |
Bitewings - two radiographic images |
41 |
36 |
$652.50 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
15 |
$0.00 |