| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,314 |
2,314 |
$126K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
843 |
450 |
$101K |
| D0330 |
Panoramic radiographic image |
1,412 |
1,411 |
$90K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,508 |
1,506 |
$84K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,135 |
3,133 |
$69K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
466 |
279 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
1,674 |
1,674 |
$43K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
319 |
175 |
$41K |
| D1120 |
Prophylaxis - child |
705 |
703 |
$27K |
| D0140 |
Limited oral evaluation - problem focused |
449 |
442 |
$19K |
| D2750 |
|
38 |
29 |
$19K |
| D0272 |
Bitewings - two radiographic images |
639 |
638 |
$16K |
| D2394 |
|
82 |
58 |
$13K |
| D0274 |
Bitewings - four radiographic images |
242 |
242 |
$7K |
| D1351 |
Sealant - per tooth |
104 |
26 |
$3K |
| D2335 |
|
25 |
12 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
16 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
49 |
49 |
$634.45 |