| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,279 |
1,235 |
$41K |
| D0274 |
Bitewings - four radiographic images |
1,397 |
1,342 |
$37K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
659 |
430 |
$33K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
391 |
231 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,894 |
1,716 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
761 |
734 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
260 |
197 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
664 |
642 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,519 |
1,451 |
$12K |
| D5110 |
|
16 |
16 |
$8K |
| D1330 |
|
1,175 |
1,143 |
$6K |
| D5214 |
|
12 |
12 |
$5K |
| D9110 |
|
210 |
198 |
$5K |
| D1351 |
Sealant - per tooth |
33 |
12 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
120 |
107 |
$3K |
| D0330 |
Panoramic radiographic image |
56 |
55 |
$2K |
| D2332 |
|
26 |
14 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
65 |
64 |
$934.71 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
12 |
12 |
$732.37 |
| D1120 |
Prophylaxis - child |
17 |
17 |
$223.75 |