| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,108 |
2,108 |
$106K |
| D0120 |
Periodic oral evaluation - established patient |
2,989 |
2,989 |
$69K |
| D1120 |
Prophylaxis - child |
1,900 |
1,900 |
$67K |
| D1206 |
Topical application of fluoride varnish |
3,726 |
3,726 |
$64K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
481 |
347 |
$54K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,269 |
1,269 |
$52K |
| D0274 |
Bitewings - four radiographic images |
1,228 |
1,228 |
$34K |
| D0140 |
Limited oral evaluation - problem focused |
441 |
439 |
$16K |
| D7140 |
Extraction, erupted tooth or exposed root |
146 |
84 |
$14K |
| D0330 |
Panoramic radiographic image |
313 |
313 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
728 |
720 |
$10K |
| D0272 |
Bitewings - two radiographic images |
196 |
196 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
46 |
38 |
$4K |
| D1351 |
Sealant - per tooth |
86 |
25 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
13 |
12 |
$2K |