| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,584 |
2,584 |
$119K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,170 |
697 |
$88K |
| D0140 |
Limited oral evaluation - problem focused |
2,184 |
2,172 |
$75K |
| D0274 |
Bitewings - four radiographic images |
2,786 |
2,786 |
$70K |
| D0330 |
Panoramic radiographic image |
1,497 |
1,496 |
$68K |
| D0220 |
Intraoral - periapical first radiographic image |
5,468 |
5,383 |
$65K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,331 |
1,331 |
$47K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
273 |
200 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
1,158 |
1,158 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
82 |
63 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
54 |
39 |
$4K |
| D1206 |
Topical application of fluoride varnish |
44 |
44 |
$709.50 |