| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,053 |
3,053 |
$151K |
| D0120 |
Periodic oral evaluation - established patient |
4,343 |
4,343 |
$98K |
| D1120 |
Prophylaxis - child |
2,808 |
2,808 |
$97K |
| D1351 |
Sealant - per tooth |
3,208 |
981 |
$95K |
| D0274 |
Bitewings - four radiographic images |
3,746 |
3,746 |
$84K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,747 |
4,747 |
$76K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
933 |
572 |
$66K |
| D0220 |
Intraoral - periapical first radiographic image |
5,220 |
5,204 |
$66K |
| D0330 |
Panoramic radiographic image |
1,191 |
1,191 |
$59K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,673 |
4,093 |
$58K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
660 |
388 |
$57K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,305 |
1,305 |
$51K |
| D0140 |
Limited oral evaluation - problem focused |
663 |
654 |
$24K |
| D0272 |
Bitewings - two radiographic images |
956 |
956 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
163 |
111 |
$14K |
| D1206 |
Topical application of fluoride varnish |
255 |
255 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
13 |
13 |
$468.00 |