| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,930 |
2,930 |
$146K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
582 |
398 |
$80K |
| D0330 |
Panoramic radiographic image |
1,215 |
1,215 |
$60K |
| D0120 |
Periodic oral evaluation - established patient |
2,555 |
2,555 |
$58K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
660 |
406 |
$49K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
469 |
321 |
$43K |
| D0140 |
Limited oral evaluation - problem focused |
1,167 |
1,165 |
$42K |
| D7140 |
Extraction, erupted tooth or exposed root |
435 |
218 |
$35K |
| D0274 |
Bitewings - four radiographic images |
934 |
934 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
630 |
630 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,372 |
1,372 |
$22K |
| D0272 |
Bitewings - two radiographic images |
995 |
995 |
$19K |
| D1120 |
Prophylaxis - child |
466 |
466 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
270 |
269 |
$3K |
| D1206 |
Topical application of fluoride varnish |
60 |
60 |
$1K |