| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
866 |
805 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
339 |
211 |
$21K |
| D0274 |
Bitewings - four radiographic images |
873 |
817 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
208 |
116 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
505 |
482 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
1,000 |
931 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
380 |
359 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
910 |
837 |
$7K |
| D1351 |
Sealant - per tooth |
94 |
39 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
34 |
28 |
$3K |
| D2331 |
|
30 |
24 |
$2K |
| D9110 |
|
50 |
47 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
22 |
12 |
$1K |
| D1206 |
Topical application of fluoride varnish |
55 |
55 |
$924.46 |
| D1120 |
Prophylaxis - child |
41 |
41 |
$901.70 |
| D0601 |
|
59 |
57 |
$530.00 |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$527.49 |
| D1330 |
|
89 |
87 |
$451.48 |
| D1310 |
|
20 |
18 |
$90.00 |