| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,926 |
1,925 |
$70K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,122 |
681 |
$59K |
| D0120 |
Periodic oral evaluation - established patient |
2,257 |
2,257 |
$41K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
704 |
410 |
$30K |
| D0274 |
Bitewings - four radiographic images |
1,800 |
1,798 |
$30K |
| D1120 |
Prophylaxis - child |
1,022 |
1,022 |
$30K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,277 |
2,967 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
3,204 |
3,158 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,666 |
1,666 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
613 |
612 |
$12K |
| D1351 |
Sealant - per tooth |
379 |
107 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
424 |
408 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
95 |
56 |
$5K |
| D4341 |
|
68 |
28 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
61 |
41 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
17 |
13 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
45 |
45 |
$1K |
| D0272 |
Bitewings - two radiographic images |
63 |
63 |
$731.60 |
| D2330 |
|
13 |
12 |
$674.95 |