| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,210 |
2,210 |
$111K |
| D0274 |
Bitewings - four radiographic images |
2,216 |
2,216 |
$60K |
| D0120 |
Periodic oral evaluation - established patient |
2,132 |
2,132 |
$48K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,215 |
2,215 |
$36K |
| D0330 |
Panoramic radiographic image |
595 |
595 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
304 |
152 |
$29K |
| D1120 |
Prophylaxis - child |
711 |
711 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
550 |
550 |
$22K |
| D7140 |
Extraction, erupted tooth or exposed root |
247 |
162 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
259 |
115 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
475 |
473 |
$6K |
| D0272 |
Bitewings - two radiographic images |
308 |
308 |
$6K |
| D1351 |
Sealant - per tooth |
117 |
42 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
90 |
90 |
$3K |