| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
5,378 |
5,378 |
$264K |
| D0120 |
Periodic oral evaluation - established patient |
9,142 |
9,142 |
$208K |
| D0274 |
Bitewings - four radiographic images |
7,491 |
7,491 |
$202K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,806 |
790 |
$178K |
| D1120 |
Prophylaxis - child |
5,114 |
5,114 |
$176K |
| D1206 |
Topical application of fluoride varnish |
10,628 |
10,628 |
$170K |
| D0220 |
Intraoral - periapical first radiographic image |
6,946 |
6,911 |
$87K |
| D7240 |
Removal of impacted tooth - completely bony |
308 |
82 |
$84K |
| D1351 |
Sealant - per tooth |
2,483 |
645 |
$74K |
| D0330 |
Panoramic radiographic image |
1,469 |
1,469 |
$70K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,286 |
1,286 |
$52K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,642 |
3,583 |
$36K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
200 |
112 |
$24K |
| D0272 |
Bitewings - two radiographic images |
1,154 |
1,154 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
125 |
86 |
$9K |
| D9222 |
|
88 |
88 |
$8K |
| D0240 |
|
327 |
171 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
100 |
99 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
65 |
65 |
$2K |
| D9310 |
|
12 |
12 |
$756.00 |