| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,072 |
3,067 |
$136K |
| D0274 |
Bitewings - four radiographic images |
3,931 |
3,928 |
$97K |
| D0120 |
Periodic oral evaluation - established patient |
3,639 |
3,622 |
$86K |
| D0220 |
Intraoral - periapical first radiographic image |
5,306 |
5,276 |
$67K |
| D1120 |
Prophylaxis - child |
1,659 |
1,658 |
$59K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
513 |
310 |
$47K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
610 |
337 |
$47K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,650 |
1,649 |
$41K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,851 |
1,851 |
$23K |
| D1351 |
Sealant - per tooth |
577 |
174 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,471 |
1,469 |
$12K |
| D0330 |
Panoramic radiographic image |
944 |
944 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
303 |
298 |
$9K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
75 |
24 |
$6K |
| D9940 |
|
44 |
44 |
$5K |
| D4341 |
|
96 |
40 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
80 |
48 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
42 |
26 |
$3K |
| D2160 |
|
22 |
15 |
$2K |
| D9944 |
|
16 |
16 |
$2K |
| D9946 |
|
12 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
89 |
89 |
$1K |
| D4910 |
|
12 |
12 |
$529.87 |
| D9110 |
|
21 |
20 |
$465.08 |
| D0140 |
Limited oral evaluation - problem focused |
26 |
26 |
$325.10 |