| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,212 |
2,209 |
$75K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
828 |
580 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
2,231 |
2,228 |
$42K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
787 |
501 |
$39K |
| D7140 |
Extraction, erupted tooth or exposed root |
479 |
166 |
$30K |
| D0330 |
Panoramic radiographic image |
813 |
812 |
$28K |
| D0272 |
Bitewings - two radiographic images |
1,617 |
1,613 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,041 |
1,039 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
981 |
980 |
$19K |
| D1120 |
Prophylaxis - child |
573 |
573 |
$17K |
| D1351 |
Sealant - per tooth |
562 |
63 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
133 |
111 |
$8K |
| D2332 |
|
92 |
69 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
89 |
38 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
715 |
693 |
$5K |
| D2331 |
|
87 |
60 |
$4K |
| D2330 |
|
92 |
60 |
$4K |
| D9110 |
|
139 |
137 |
$4K |
| D0274 |
Bitewings - four radiographic images |
107 |
107 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
16 |
12 |
$880.00 |