| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
5,536 |
5,536 |
$280K |
| D0120 |
Periodic oral evaluation - established patient |
5,813 |
5,812 |
$152K |
| D0330 |
Panoramic radiographic image |
2,249 |
2,249 |
$80K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,023 |
1,023 |
$30K |
| D0272 |
Bitewings - two radiographic images |
1,964 |
1,964 |
$28K |
| D1120 |
Prophylaxis - child |
483 |
482 |
$20K |
| D0274 |
Bitewings - four radiographic images |
829 |
829 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
236 |
198 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
476 |
476 |
$6K |
| D9920 |
|
220 |
217 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
57 |
56 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
398 |
398 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
34 |
27 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
87 |
87 |
$1K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
13 |
13 |
$1K |