| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,897 |
1,897 |
$107K |
| D0120 |
Periodic oral evaluation - established patient |
2,818 |
2,816 |
$79K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
718 |
612 |
$76K |
| D1120 |
Prophylaxis - child |
1,770 |
1,770 |
$75K |
| D1351 |
Sealant - per tooth |
591 |
498 |
$58K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
570 |
493 |
$41K |
| D0330 |
Panoramic radiographic image |
879 |
879 |
$33K |
| D0274 |
Bitewings - four radiographic images |
971 |
971 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
829 |
828 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,701 |
1,700 |
$24K |
| D1206 |
Topical application of fluoride varnish |
686 |
686 |
$21K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
184 |
160 |
$18K |
| D0272 |
Bitewings - two radiographic images |
630 |
630 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
575 |
568 |
$8K |
| D2331 |
|
53 |
50 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
329 |
328 |
$6K |
| D9110 |
|
50 |
50 |
$1K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
12 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
38 |
38 |
$472.36 |