| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,050 |
2,043 |
$85K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,132 |
681 |
$82K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
798 |
398 |
$52K |
| D0274 |
Bitewings - four radiographic images |
2,008 |
1,997 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
1,387 |
1,384 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,058 |
1,049 |
$23K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
249 |
153 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,664 |
1,630 |
$20K |
| D0330 |
Panoramic radiographic image |
823 |
816 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
353 |
178 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,286 |
1,246 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
156 |
156 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
35 |
25 |
$2K |
| D1206 |
Topical application of fluoride varnish |
44 |
44 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
25 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
46 |
46 |
$550.65 |
| D1120 |
Prophylaxis - child |
15 |
15 |
$485.00 |