| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,719 |
2,719 |
$137K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,379 |
747 |
$120K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
958 |
541 |
$88K |
| D0120 |
Periodic oral evaluation - established patient |
2,989 |
2,989 |
$68K |
| D0140 |
Limited oral evaluation - problem focused |
1,392 |
1,391 |
$51K |
| D0272 |
Bitewings - two radiographic images |
2,488 |
2,488 |
$47K |
| D0220 |
Intraoral - periapical first radiographic image |
3,228 |
3,208 |
$41K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,221 |
2,221 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
650 |
650 |
$26K |
| D1120 |
Prophylaxis - child |
529 |
529 |
$18K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
98 |
62 |
$13K |
| D0330 |
Panoramic radiographic image |
276 |
276 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,270 |
1,227 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
117 |
74 |
$9K |
| D0274 |
Bitewings - four radiographic images |
281 |
281 |
$8K |