| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,487 |
4,487 |
$217K |
| D0274 |
Bitewings - four radiographic images |
5,511 |
5,511 |
$145K |
| D0120 |
Periodic oral evaluation - established patient |
5,496 |
5,496 |
$121K |
| D0330 |
Panoramic radiographic image |
1,669 |
1,669 |
$80K |
| D1206 |
Topical application of fluoride varnish |
4,430 |
4,430 |
$71K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
738 |
481 |
$69K |
| D1120 |
Prophylaxis - child |
1,994 |
1,994 |
$68K |
| D0220 |
Intraoral - periapical first radiographic image |
5,277 |
5,255 |
$65K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,633 |
4,248 |
$52K |
| D0140 |
Limited oral evaluation - problem focused |
967 |
966 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
769 |
769 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
356 |
239 |
$28K |
| D7140 |
Extraction, erupted tooth or exposed root |
344 |
187 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
932 |
932 |
$15K |
| D1351 |
Sealant - per tooth |
68 |
16 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
83 |
83 |
$1K |