| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
7,613 |
7,603 |
$331K |
| D0120 |
Periodic oral evaluation - established patient |
14,425 |
14,414 |
$318K |
| D1120 |
Prophylaxis - child |
7,421 |
7,417 |
$245K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,011 |
1,681 |
$119K |
| D1208 |
Topical application of fluoride, excluding varnish |
10,067 |
10,058 |
$110K |
| D1351 |
Sealant - per tooth |
1,351 |
659 |
$87K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,183 |
1,023 |
$86K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,677 |
6,567 |
$82K |
| D0220 |
Intraoral - periapical first radiographic image |
7,370 |
7,344 |
$73K |
| D0274 |
Bitewings - four radiographic images |
3,308 |
3,308 |
$68K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,366 |
1,154 |
$59K |
| D1206 |
Topical application of fluoride varnish |
1,740 |
1,740 |
$40K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
875 |
737 |
$34K |
| D0330 |
Panoramic radiographic image |
904 |
904 |
$29K |
| D0140 |
Limited oral evaluation - problem focused |
1,943 |
1,912 |
$23K |
| D0240 |
|
1,010 |
950 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
853 |
850 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
233 |
233 |
$5K |
| D2394 |
|
13 |
13 |
$1K |
| D0272 |
Bitewings - two radiographic images |
63 |
63 |
$805.50 |
| D2331 |
|
13 |
12 |
$790.47 |