| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,460 |
3,394 |
$214K |
| D0120 |
Periodic oral evaluation - established patient |
5,787 |
5,693 |
$172K |
| D1208 |
Topical application of fluoride, excluding varnish |
7,284 |
7,164 |
$167K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,558 |
652 |
$158K |
| D1120 |
Prophylaxis - child |
3,538 |
3,492 |
$152K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,131 |
617 |
$145K |
| D2750 |
|
334 |
256 |
$140K |
| D1351 |
Sealant - per tooth |
3,268 |
646 |
$108K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,820 |
1,782 |
$97K |
| D0274 |
Bitewings - four radiographic images |
2,170 |
2,126 |
$50K |
| D0140 |
Limited oral evaluation - problem focused |
1,063 |
923 |
$48K |
| D4341 |
|
584 |
144 |
$46K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
286 |
181 |
$45K |
| D0330 |
Panoramic radiographic image |
641 |
628 |
$29K |
| D1330 |
|
3,233 |
3,187 |
$20K |
| D1206 |
Topical application of fluoride varnish |
421 |
397 |
$10K |
| D3320 |
|
15 |
12 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
833 |
772 |
$9K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
65 |
39 |
$7K |
| D2950 |
|
64 |
57 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
49 |
25 |
$5K |
| D2330 |
|
40 |
20 |
$4K |
| D0272 |
Bitewings - two radiographic images |
103 |
103 |
$2K |
| D3120 |
|
52 |
27 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
51 |
50 |
$498.56 |