| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,618 |
2,618 |
$128K |
| D0120 |
Periodic oral evaluation - established patient |
3,898 |
3,898 |
$86K |
| D1120 |
Prophylaxis - child |
1,898 |
1,898 |
$65K |
| D0274 |
Bitewings - four radiographic images |
2,066 |
2,066 |
$55K |
| D0330 |
Panoramic radiographic image |
831 |
831 |
$40K |
| D0140 |
Limited oral evaluation - problem focused |
745 |
743 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,298 |
1,298 |
$21K |
| D0272 |
Bitewings - two radiographic images |
879 |
879 |
$16K |
| D7140 |
Extraction, erupted tooth or exposed root |
171 |
92 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
98 |
74 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
178 |
178 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
475 |
472 |
$6K |
| D1206 |
Topical application of fluoride varnish |
301 |
301 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
42 |
25 |
$3K |
| D1351 |
Sealant - per tooth |
49 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
12 |
$134.43 |