| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
502 |
480 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
138 |
91 |
$10K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
51 |
28 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
392 |
380 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
337 |
322 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
142 |
141 |
$6K |
| D0274 |
Bitewings - four radiographic images |
252 |
245 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
82 |
60 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
89 |
85 |
$1K |
| D0330 |
Panoramic radiographic image |
32 |
32 |
$1K |
| D1120 |
Prophylaxis - child |
59 |
53 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
81 |
78 |
$557.66 |
| D1310 |
|
76 |
74 |
$506.31 |
| D1330 |
|
74 |
73 |
$495.80 |
| D9110 |
|
15 |
12 |
$328.39 |