| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,830 |
1,830 |
$108K |
| D0120 |
Periodic oral evaluation - established patient |
1,663 |
1,663 |
$49K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
386 |
233 |
$38K |
| D0274 |
Bitewings - four radiographic images |
1,111 |
1,111 |
$28K |
| D0330 |
Panoramic radiographic image |
446 |
446 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
424 |
424 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
892 |
884 |
$11K |
| D2740 |
Crown - porcelain/ceramic |
13 |
12 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
77 |
56 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
103 |
51 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
324 |
319 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
210 |
209 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
38 |
28 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
588 |
519 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
12 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$210.93 |