| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,364 |
1,364 |
$72K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
647 |
396 |
$57K |
| D0120 |
Periodic oral evaluation - established patient |
1,171 |
1,171 |
$31K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
277 |
150 |
$26K |
| D0274 |
Bitewings - four radiographic images |
952 |
952 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
342 |
218 |
$22K |
| D0330 |
Panoramic radiographic image |
557 |
555 |
$18K |
| D2954 |
|
72 |
64 |
$18K |
| D2750 |
|
15 |
12 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
353 |
353 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
76 |
56 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
243 |
238 |
$3K |
| D1120 |
Prophylaxis - child |
59 |
59 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
111 |
111 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
26 |
13 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
39 |
39 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
59 |
59 |
$795.20 |
| D0230 |
Intraoral - periapical each additional radiographic image |
68 |
51 |
$518.85 |