| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,564 |
3,563 |
$196K |
| D0274 |
Bitewings - four radiographic images |
2,846 |
2,846 |
$100K |
| D0120 |
Periodic oral evaluation - established patient |
2,670 |
2,670 |
$74K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,913 |
2,911 |
$65K |
| D0330 |
Panoramic radiographic image |
1,188 |
1,188 |
$44K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,205 |
1,205 |
$35K |
| D7140 |
Extraction, erupted tooth or exposed root |
641 |
330 |
$31K |
| D0220 |
Intraoral - periapical first radiographic image |
1,227 |
1,227 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
294 |
209 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
817 |
817 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
160 |
124 |
$12K |
| D2740 |
Crown - porcelain/ceramic |
19 |
12 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
626 |
625 |
$9K |
| D1120 |
Prophylaxis - child |
13 |
13 |
$518.70 |