| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,471 |
2,470 |
$133K |
| D0120 |
Periodic oral evaluation - established patient |
3,055 |
3,055 |
$83K |
| D0274 |
Bitewings - four radiographic images |
2,088 |
2,088 |
$56K |
| D1120 |
Prophylaxis - child |
826 |
825 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
345 |
235 |
$27K |
| D0330 |
Panoramic radiographic image |
621 |
621 |
$24K |
| D1354 |
|
1,418 |
255 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,496 |
1,495 |
$21K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
154 |
118 |
$12K |
| D0272 |
Bitewings - two radiographic images |
718 |
718 |
$12K |
| D1351 |
Sealant - per tooth |
273 |
93 |
$11K |
| D2752 |
|
18 |
12 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
732 |
730 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
548 |
548 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
230 |
230 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
689 |
689 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
102 |
71 |
$5K |
| D1206 |
Topical application of fluoride varnish |
107 |
107 |
$3K |
| D2335 |
|
23 |
15 |
$3K |
| D9996 |
|
164 |
159 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
42 |
27 |
$2K |
| D2160 |
|
13 |
12 |
$1K |