| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,753 |
2,753 |
$135K |
| D0330 |
Panoramic radiographic image |
1,561 |
1,561 |
$71K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,733 |
1,732 |
$68K |
| D0274 |
Bitewings - four radiographic images |
2,604 |
2,604 |
$63K |
| D7140 |
Extraction, erupted tooth or exposed root |
765 |
482 |
$62K |
| D0140 |
Limited oral evaluation - problem focused |
1,289 |
1,289 |
$48K |
| D0120 |
Periodic oral evaluation - established patient |
1,546 |
1,546 |
$35K |
| D0220 |
Intraoral - periapical first radiographic image |
2,193 |
2,183 |
$23K |
| D1206 |
Topical application of fluoride varnish |
1,161 |
1,161 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
97 |
88 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
98 |
88 |
$8K |
| D1120 |
Prophylaxis - child |
30 |
30 |
$1K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$170.46 |