| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,222 |
3,221 |
$126K |
| D0274 |
Bitewings - four radiographic images |
2,597 |
2,595 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
2,299 |
2,298 |
$50K |
| D0210 |
Intraoral - complete series of radiographic images |
1,162 |
1,162 |
$44K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,699 |
1,699 |
$40K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
587 |
255 |
$36K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
644 |
282 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
2,803 |
2,796 |
$24K |
| D2750 |
|
50 |
41 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,724 |
2,720 |
$14K |
| D1120 |
Prophylaxis - child |
324 |
324 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
787 |
786 |
$10K |
| D1351 |
Sealant - per tooth |
147 |
42 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
82 |
35 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
189 |
187 |
$2K |