| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,538 |
3,538 |
$176K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,362 |
922 |
$122K |
| D0330 |
Panoramic radiographic image |
2,724 |
2,723 |
$121K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,441 |
861 |
$118K |
| D1120 |
Prophylaxis - child |
3,089 |
3,089 |
$108K |
| D0120 |
Periodic oral evaluation - established patient |
4,346 |
4,346 |
$99K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,649 |
5,649 |
$93K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,300 |
2,299 |
$93K |
| D0272 |
Bitewings - two radiographic images |
4,750 |
4,750 |
$90K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
489 |
377 |
$48K |
| D0220 |
Intraoral - periapical first radiographic image |
3,074 |
2,982 |
$38K |
| D0140 |
Limited oral evaluation - problem focused |
631 |
628 |
$23K |
| D0274 |
Bitewings - four radiographic images |
775 |
775 |
$21K |
| D1351 |
Sealant - per tooth |
162 |
55 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
365 |
326 |
$4K |