| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,595 |
2,595 |
$124K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,192 |
598 |
$106K |
| D0274 |
Bitewings - four radiographic images |
3,064 |
3,064 |
$79K |
| D0120 |
Periodic oral evaluation - established patient |
2,384 |
2,384 |
$53K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
434 |
289 |
$46K |
| D0220 |
Intraoral - periapical first radiographic image |
3,337 |
3,306 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
895 |
895 |
$35K |
| D0330 |
Panoramic radiographic image |
683 |
683 |
$31K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,599 |
2,479 |
$24K |
| D1120 |
Prophylaxis - child |
670 |
670 |
$23K |
| D1206 |
Topical application of fluoride varnish |
1,196 |
1,196 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
492 |
482 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
773 |
773 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
106 |
74 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
12 |
$2K |