| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,952 |
1,923 |
$64K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,256 |
781 |
$62K |
| D0274 |
Bitewings - four radiographic images |
2,190 |
2,155 |
$57K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,335 |
1,316 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
1,277 |
1,265 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
402 |
306 |
$22K |
| D0330 |
Panoramic radiographic image |
641 |
641 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
437 |
268 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
2,477 |
2,319 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,017 |
1,892 |
$15K |
| D7140 |
Extraction, erupted tooth or exposed root |
210 |
97 |
$9K |
| D9110 |
|
274 |
267 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
102 |
102 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
159 |
159 |
$2K |
| D1351 |
Sealant - per tooth |
86 |
12 |
$2K |
| D1120 |
Prophylaxis - child |
50 |
50 |
$1K |
| D1330 |
|
767 |
762 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
13 |
12 |
$770.30 |
| D0140 |
Limited oral evaluation - problem focused |
26 |
25 |
$462.88 |