| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,861 |
2,861 |
$143K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,306 |
876 |
$121K |
| D0274 |
Bitewings - four radiographic images |
2,803 |
2,803 |
$76K |
| D0120 |
Periodic oral evaluation - established patient |
2,625 |
2,625 |
$61K |
| D0330 |
Panoramic radiographic image |
945 |
945 |
$45K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,576 |
2,576 |
$42K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
999 |
999 |
$40K |
| D0140 |
Limited oral evaluation - problem focused |
645 |
641 |
$24K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
182 |
140 |
$20K |
| D1120 |
Prophylaxis - child |
478 |
478 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
208 |
154 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,127 |
1,110 |
$14K |
| D0272 |
Bitewings - two radiographic images |
717 |
717 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
101 |
63 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
30 |
29 |
$296.80 |