| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,525 |
2,467 |
$106K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,270 |
3,202 |
$85K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,221 |
820 |
$64K |
| D0274 |
Bitewings - four radiographic images |
1,640 |
1,604 |
$41K |
| D0330 |
Panoramic radiographic image |
867 |
848 |
$32K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
538 |
428 |
$32K |
| D1120 |
Prophylaxis - child |
580 |
570 |
$27K |
| D0140 |
Limited oral evaluation - problem focused |
651 |
612 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
466 |
263 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,915 |
1,809 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
965 |
940 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
216 |
167 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
159 |
156 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
675 |
353 |
$4K |
| D2394 |
|
47 |
29 |
$3K |
| D9110 |
|
125 |
111 |
$2K |
| D2335 |
|
21 |
12 |
$1K |
| D1206 |
Topical application of fluoride varnish |
68 |
67 |
$1K |
| D1351 |
Sealant - per tooth |
42 |
12 |
$757.58 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$666.89 |