| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,936 |
4,936 |
$230K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,982 |
1,489 |
$127K |
| D0120 |
Periodic oral evaluation - established patient |
4,210 |
4,210 |
$98K |
| D0274 |
Bitewings - four radiographic images |
4,216 |
4,215 |
$98K |
| D0220 |
Intraoral - periapical first radiographic image |
6,681 |
6,612 |
$76K |
| D1120 |
Prophylaxis - child |
1,336 |
1,336 |
$48K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,015 |
5,005 |
$37K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
431 |
395 |
$33K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
726 |
605 |
$31K |
| D0330 |
Panoramic radiographic image |
780 |
780 |
$24K |
| D2750 |
|
54 |
51 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,748 |
1,747 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
1,239 |
1,225 |
$13K |
| D2331 |
|
184 |
148 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
1,128 |
1,120 |
$11K |
| D2954 |
|
91 |
86 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
411 |
411 |
$9K |
| D0272 |
Bitewings - two radiographic images |
630 |
629 |
$9K |
| D1351 |
Sealant - per tooth |
194 |
67 |
$7K |
| D0270 |
|
442 |
438 |
$5K |
| D2330 |
|
15 |
12 |
$696.34 |
| D7140 |
Extraction, erupted tooth or exposed root |
17 |
12 |
$626.74 |