| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,128 |
1,102 |
$34K |
| D0210 |
Intraoral - complete series of radiographic images |
603 |
583 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
1,039 |
1,012 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
479 |
329 |
$19K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,011 |
334 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
608 |
400 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,060 |
1,035 |
$17K |
| D1120 |
Prophylaxis - child |
690 |
680 |
$6K |
| D1206 |
Topical application of fluoride varnish |
1,680 |
1,644 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
58 |
41 |
$4K |
| D0274 |
Bitewings - four radiographic images |
276 |
270 |
$987.96 |
| D0272 |
Bitewings - two radiographic images |
301 |
292 |
$881.73 |
| D2330 |
|
23 |
13 |
$661.40 |
| D2331 |
|
21 |
14 |
$495.47 |
| D1351 |
Sealant - per tooth |
38 |
12 |
$482.35 |
| D9999 |
Unspecified adjunctive procedure, by report |
12 |
12 |
$300.00 |
| D0220 |
Intraoral - periapical first radiographic image |
75 |
71 |
$24.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
12 |
$0.00 |