| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
12,676 |
12,673 |
$432K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
10,659 |
10,658 |
$220K |
| D0330 |
Panoramic radiographic image |
7,466 |
7,460 |
$169K |
| D0274 |
Bitewings - four radiographic images |
10,569 |
10,566 |
$166K |
| D0220 |
Intraoral - periapical first radiographic image |
16,078 |
15,965 |
$128K |
| D0120 |
Periodic oral evaluation - established patient |
6,540 |
6,534 |
$124K |
| D0230 |
Intraoral - periapical each additional radiographic image |
13,764 |
13,266 |
$87K |
| D0210 |
Intraoral - complete series of radiographic images |
6,701 |
6,641 |
$48K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
760 |
468 |
$38K |
| D1120 |
Prophylaxis - child |
966 |
965 |
$30K |
| D2750 |
|
66 |
40 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
489 |
297 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
849 |
830 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
723 |
721 |
$7K |
| D1351 |
Sealant - per tooth |
122 |
27 |
$4K |
| D1206 |
Topical application of fluoride varnish |
140 |
140 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
47 |
28 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
13 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
28 |
13 |
$940.14 |
| D9110 |
|
39 |
38 |
$563.02 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$141.91 |