| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,318 |
2,318 |
$115K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
900 |
404 |
$81K |
| D0274 |
Bitewings - four radiographic images |
2,723 |
2,723 |
$73K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,790 |
1,790 |
$70K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
389 |
185 |
$52K |
| D0330 |
Panoramic radiographic image |
950 |
950 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
1,499 |
1,499 |
$34K |
| D0220 |
Intraoral - periapical first radiographic image |
2,342 |
2,235 |
$29K |
| D1206 |
Topical application of fluoride varnish |
1,379 |
1,379 |
$23K |
| D1120 |
Prophylaxis - child |
602 |
602 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,970 |
1,897 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
137 |
79 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
57 |
27 |
$7K |
| D0272 |
Bitewings - two radiographic images |
118 |
118 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
38 |
38 |
$583.20 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$412.34 |