| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,174 |
1,152 |
$60K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
342 |
219 |
$47K |
| D0330 |
Panoramic radiographic image |
894 |
880 |
$46K |
| D7140 |
Extraction, erupted tooth or exposed root |
582 |
222 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
859 |
845 |
$37K |
| D0274 |
Bitewings - four radiographic images |
1,163 |
1,142 |
$36K |
| D0140 |
Limited oral evaluation - problem focused |
730 |
711 |
$29K |
| D1120 |
Prophylaxis - child |
449 |
441 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
802 |
792 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
236 |
157 |
$17K |
| D1206 |
Topical application of fluoride varnish |
627 |
618 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
259 |
147 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
818 |
794 |
$11K |
| D1351 |
Sealant - per tooth |
124 |
25 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
13 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
133 |
83 |
$1K |
| D0272 |
Bitewings - two radiographic images |
24 |
24 |
$565.00 |