| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,082 |
3,082 |
$153K |
| D0120 |
Periodic oral evaluation - established patient |
5,268 |
5,268 |
$122K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,938 |
4,938 |
$81K |
| D1120 |
Prophylaxis - child |
2,023 |
2,023 |
$71K |
| D0330 |
Panoramic radiographic image |
1,308 |
1,308 |
$66K |
| D0272 |
Bitewings - two radiographic images |
3,152 |
3,152 |
$60K |
| D0140 |
Limited oral evaluation - problem focused |
1,018 |
1,012 |
$37K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
304 |
154 |
$31K |
| D7140 |
Extraction, erupted tooth or exposed root |
376 |
226 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
140 |
88 |
$15K |
| D0274 |
Bitewings - four radiographic images |
441 |
441 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
43 |
43 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
15 |
15 |
$172.05 |