| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
925 |
905 |
$28K |
| D0330 |
Panoramic radiographic image |
630 |
606 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
556 |
541 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
825 |
811 |
$13K |
| D0274 |
Bitewings - four radiographic images |
629 |
614 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
535 |
527 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
385 |
372 |
$7K |
| D1120 |
Prophylaxis - child |
355 |
350 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
79 |
25 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
79 |
49 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
64 |
37 |
$3K |
| D1351 |
Sealant - per tooth |
93 |
18 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
553 |
529 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
389 |
224 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
30 |
12 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
24 |
12 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
18 |
17 |
$780.00 |
| D0272 |
Bitewings - two radiographic images |
18 |
18 |
$110.00 |