| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,726 |
1,726 |
$83K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,568 |
1,568 |
$59K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
612 |
376 |
$55K |
| D0274 |
Bitewings - four radiographic images |
2,076 |
2,076 |
$55K |
| D0330 |
Panoramic radiographic image |
944 |
944 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
734 |
734 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
742 |
742 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
668 |
654 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
54 |
25 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
141 |
141 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
56 |
37 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
13 |
$1K |
| D1206 |
Topical application of fluoride varnish |
64 |
64 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
15 |
14 |
$121.48 |