| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,906 |
2,798 |
$87K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
651 |
429 |
$56K |
| D0330 |
Panoramic radiographic image |
1,151 |
1,119 |
$43K |
| D0140 |
Limited oral evaluation - problem focused |
2,152 |
2,042 |
$41K |
| D7140 |
Extraction, erupted tooth or exposed root |
417 |
177 |
$36K |
| D0274 |
Bitewings - four radiographic images |
2,741 |
2,633 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
1,822 |
1,759 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,177 |
1,133 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
3,426 |
3,214 |
$19K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
152 |
104 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
155 |
97 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,300 |
2,050 |
$9K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
25 |
12 |
$875.00 |
| D0210 |
Intraoral - complete series of radiographic images |
27 |
24 |
$516.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$76.00 |
| D1330 |
|
15 |
15 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
20 |
20 |
$0.00 |