| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,916 |
1,908 |
$61K |
| D0274 |
Bitewings - four radiographic images |
2,178 |
2,170 |
$54K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
993 |
355 |
$47K |
| D0120 |
Periodic oral evaluation - established patient |
1,920 |
1,909 |
$36K |
| D2740 |
Crown - porcelain/ceramic |
82 |
48 |
$31K |
| D1351 |
Sealant - per tooth |
1,240 |
201 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
436 |
242 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
2,443 |
2,388 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
923 |
916 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,117 |
2,072 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
986 |
977 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
237 |
140 |
$14K |
| D1120 |
Prophylaxis - child |
504 |
497 |
$12K |
| D0330 |
Panoramic radiographic image |
249 |
249 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
102 |
41 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
95 |
94 |
$2K |
| D2332 |
|
24 |
13 |
$1K |