| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,379 |
2,914 |
$170K |
| D1206 |
Topical application of fluoride varnish |
4,367 |
3,665 |
$105K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
767 |
420 |
$100K |
| D0120 |
Periodic oral evaluation - established patient |
3,485 |
2,995 |
$98K |
| D1120 |
Prophylaxis - child |
1,393 |
1,149 |
$60K |
| D0330 |
Panoramic radiographic image |
913 |
769 |
$60K |
| D0274 |
Bitewings - four radiographic images |
1,402 |
1,208 |
$49K |
| D1351 |
Sealant - per tooth |
3,236 |
545 |
$49K |
| D9920 |
|
1,045 |
865 |
$31K |
| D0220 |
Intraoral - periapical first radiographic image |
1,619 |
1,292 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
500 |
440 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
260 |
145 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,432 |
670 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
480 |
402 |
$20K |
| D7140 |
Extraction, erupted tooth or exposed root |
185 |
98 |
$19K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
117 |
72 |
$18K |
| D4346 |
|
249 |
193 |
$14K |
| D1354 |
|
631 |
135 |
$13K |
| D4355 |
|
113 |
97 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
162 |
137 |
$12K |
| D0272 |
Bitewings - two radiographic images |
376 |
315 |
$10K |
| D4341 |
|
48 |
14 |
$8K |
| D1330 |
|
274 |
239 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
367 |
314 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
38 |
13 |
$5K |
| D2950 |
|
20 |
12 |
$2K |
| D2331 |
|
16 |
12 |
$2K |
| D1353 |
|
92 |
38 |
$0.00 |