| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,902 |
2,753 |
$157K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,494 |
584 |
$121K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
814 |
467 |
$105K |
| D0120 |
Periodic oral evaluation - established patient |
3,189 |
3,044 |
$78K |
| D0274 |
Bitewings - four radiographic images |
1,710 |
1,598 |
$63K |
| D0140 |
Limited oral evaluation - problem focused |
1,615 |
1,513 |
$63K |
| D1120 |
Prophylaxis - child |
1,234 |
1,143 |
$59K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,085 |
1,977 |
$58K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
905 |
835 |
$38K |
| D0220 |
Intraoral - periapical first radiographic image |
2,603 |
2,408 |
$36K |
| D1351 |
Sealant - per tooth |
696 |
155 |
$25K |
| D0210 |
Intraoral - complete series of radiographic images |
298 |
282 |
$21K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
171 |
84 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,004 |
804 |
$13K |
| D0330 |
Panoramic radiographic image |
60 |
57 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
52 |
29 |
$3K |
| D9110 |
|
19 |
16 |
$579.00 |