| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,166 |
3,087 |
$162K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,500 |
940 |
$112K |
| D0120 |
Periodic oral evaluation - established patient |
3,617 |
3,528 |
$83K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,349 |
747 |
$80K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
591 |
345 |
$80K |
| D1120 |
Prophylaxis - child |
1,108 |
1,088 |
$54K |
| D0274 |
Bitewings - four radiographic images |
1,480 |
1,439 |
$50K |
| D0220 |
Intraoral - periapical first radiographic image |
2,680 |
2,555 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
880 |
856 |
$35K |
| D0140 |
Limited oral evaluation - problem focused |
745 |
731 |
$29K |
| D0210 |
Intraoral - complete series of radiographic images |
432 |
411 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
741 |
725 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,860 |
1,544 |
$21K |
| D0330 |
Panoramic radiographic image |
242 |
237 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
145 |
122 |
$12K |
| D1206 |
Topical application of fluoride varnish |
430 |
421 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
112 |
56 |
$7K |
| D1351 |
Sealant - per tooth |
65 |
15 |
$2K |
| D0272 |
Bitewings - two radiographic images |
46 |
44 |
$1K |
| D9110 |
|
26 |
26 |
$1K |
| D2330 |
|
14 |
12 |
$883.40 |