| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,888 |
1,886 |
$62K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
831 |
513 |
$44K |
| D0210 |
Intraoral - complete series of radiographic images |
779 |
775 |
$33K |
| D0274 |
Bitewings - four radiographic images |
1,224 |
1,223 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
1,660 |
1,655 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,261 |
1,256 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
378 |
236 |
$17K |
| D0330 |
Panoramic radiographic image |
471 |
469 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,286 |
1,235 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
160 |
120 |
$9K |
| D1351 |
Sealant - per tooth |
257 |
28 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
337 |
337 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
718 |
700 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
61 |
51 |
$3K |
| D1120 |
Prophylaxis - child |
112 |
112 |
$2K |
| D0602 |
|
198 |
198 |
$2K |
| D1330 |
|
383 |
383 |
$2K |
| D2332 |
|
24 |
15 |
$1K |
| D9110 |
|
49 |
48 |
$1K |
| D0601 |
|
102 |
102 |
$960.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
14 |
13 |
$627.36 |
| D0603 |
|
25 |
25 |
$250.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$203.10 |