| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,152 |
2,149 |
$74K |
| D0120 |
Periodic oral evaluation - established patient |
2,226 |
2,223 |
$42K |
| D0274 |
Bitewings - four radiographic images |
1,382 |
1,380 |
$37K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
473 |
346 |
$28K |
| D0330 |
Panoramic radiographic image |
717 |
714 |
$25K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
344 |
266 |
$22K |
| D7140 |
Extraction, erupted tooth or exposed root |
240 |
43 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
284 |
203 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
663 |
662 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
502 |
500 |
$10K |
| D1120 |
Prophylaxis - child |
121 |
121 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
537 |
528 |
$4K |
| D1351 |
Sealant - per tooth |
122 |
15 |
$3K |
| D0272 |
Bitewings - two radiographic images |
65 |
65 |
$1K |
| D1330 |
|
87 |
87 |
$953.21 |
| D1310 |
|
87 |
87 |
$935.15 |
| D2331 |
|
16 |
12 |
$903.60 |
| D0230 |
Intraoral - periapical each additional radiographic image |
45 |
39 |
$496.24 |
| D9110 |
|
12 |
12 |
$368.00 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
13 |
$269.75 |