| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,497 |
1,497 |
$73K |
| D0330 |
Panoramic radiographic image |
1,392 |
1,390 |
$67K |
| D7140 |
Extraction, erupted tooth or exposed root |
756 |
429 |
$61K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,420 |
1,420 |
$58K |
| D1120 |
Prophylaxis - child |
1,050 |
1,050 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
1,356 |
1,356 |
$32K |
| D0274 |
Bitewings - four radiographic images |
1,156 |
1,156 |
$28K |
| D1206 |
Topical application of fluoride varnish |
1,718 |
1,718 |
$28K |
| D0140 |
Limited oral evaluation - problem focused |
618 |
613 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
282 |
234 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
225 |
178 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
235 |
234 |
$3K |
| D0272 |
Bitewings - two radiographic images |
189 |
189 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
42 |
42 |
$403.59 |