| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2750 |
|
775 |
696 |
$307K |
| D1110 |
Prophylaxis - adult |
5,355 |
5,351 |
$193K |
| D0120 |
Periodic oral evaluation - established patient |
6,779 |
6,773 |
$135K |
| D0274 |
Bitewings - four radiographic images |
5,601 |
5,598 |
$106K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,491 |
1,047 |
$90K |
| D1351 |
Sealant - per tooth |
1,438 |
537 |
$67K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,483 |
6,478 |
$60K |
| D0220 |
Intraoral - periapical first radiographic image |
6,144 |
6,143 |
$56K |
| D2954 |
|
553 |
503 |
$54K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
905 |
652 |
$37K |
| D1120 |
Prophylaxis - child |
1,150 |
1,148 |
$35K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,157 |
2,156 |
$25K |
| D9110 |
|
742 |
740 |
$12K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
26 |
25 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
207 |
207 |
$3K |
| D3320 |
|
12 |
12 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
16 |
13 |
$633.84 |