| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
5,359 |
5,354 |
$224K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,763 |
1,322 |
$144K |
| D0120 |
Periodic oral evaluation - established patient |
4,500 |
4,497 |
$97K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,289 |
880 |
$90K |
| D0210 |
Intraoral - complete series of radiographic images |
1,451 |
1,450 |
$52K |
| D0272 |
Bitewings - two radiographic images |
2,864 |
2,863 |
$37K |
| D0220 |
Intraoral - periapical first radiographic image |
4,189 |
4,176 |
$36K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,355 |
3,351 |
$24K |
| D0274 |
Bitewings - four radiographic images |
776 |
776 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,606 |
1,604 |
$16K |
| D1120 |
Prophylaxis - child |
297 |
297 |
$10K |
| D2335 |
|
73 |
40 |
$8K |
| D2750 |
|
18 |
12 |
$6K |
| D1320 |
|
629 |
629 |
$5K |
| D0330 |
Panoramic radiographic image |
142 |
142 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
350 |
350 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
20 |
19 |
$733.95 |