| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,115 |
3,115 |
$149K |
| D0120 |
Periodic oral evaluation - established patient |
3,863 |
3,863 |
$87K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,033 |
521 |
$81K |
| D1120 |
Prophylaxis - child |
2,225 |
2,225 |
$77K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,057 |
4,057 |
$66K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,602 |
1,602 |
$65K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
474 |
296 |
$63K |
| D0140 |
Limited oral evaluation - problem focused |
1,259 |
1,255 |
$46K |
| D0330 |
Panoramic radiographic image |
821 |
820 |
$41K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
251 |
148 |
$24K |
| D0274 |
Bitewings - four radiographic images |
791 |
791 |
$21K |
| D0272 |
Bitewings - two radiographic images |
637 |
637 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
737 |
726 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
79 |
37 |
$4K |
| D1351 |
Sealant - per tooth |
74 |
19 |
$2K |
| D0240 |
|
27 |
27 |
$511.38 |