| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
5,193 |
4,943 |
$212K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,169 |
1,341 |
$167K |
| D0120 |
Periodic oral evaluation - established patient |
7,764 |
7,503 |
$141K |
| D0274 |
Bitewings - four radiographic images |
6,147 |
5,858 |
$136K |
| D0230 |
Intraoral - periapical each additional radiographic image |
18,688 |
4,175 |
$130K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
5,186 |
3,816 |
$112K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,080 |
752 |
$107K |
| D0330 |
Panoramic radiographic image |
3,062 |
1,740 |
$94K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,655 |
4,598 |
$93K |
| D1120 |
Prophylaxis - child |
2,810 |
2,782 |
$91K |
| D0210 |
Intraoral - complete series of radiographic images |
3,759 |
2,705 |
$83K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,288 |
357 |
$70K |
| D0220 |
Intraoral - periapical first radiographic image |
6,599 |
4,509 |
$47K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
373 |
266 |
$25K |
| D4355 |
|
155 |
151 |
$12K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
112 |
40 |
$9K |
| D1206 |
Topical application of fluoride varnish |
254 |
251 |
$5K |
| D2950 |
|
45 |
26 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
31 |
26 |
$620.75 |