| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,200 |
4,130 |
$259K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,100 |
879 |
$253K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,070 |
2,028 |
$128K |
| D0330 |
Panoramic radiographic image |
1,911 |
1,871 |
$121K |
| D0274 |
Bitewings - four radiographic images |
2,324 |
2,285 |
$82K |
| D0120 |
Periodic oral evaluation - established patient |
2,759 |
2,719 |
$78K |
| D0220 |
Intraoral - periapical first radiographic image |
1,343 |
1,326 |
$21K |
| D1206 |
Topical application of fluoride varnish |
578 |
570 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,055 |
1,044 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
135 |
73 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
60 |
43 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
96 |
94 |
$7K |
| D1120 |
Prophylaxis - child |
118 |
118 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
42 |
15 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
67 |
67 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
23 |
23 |
$575.00 |