| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,228 |
1,222 |
$43K |
| D1351 |
Sealant - per tooth |
1,585 |
355 |
$39K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
520 |
387 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
1,198 |
1,193 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
476 |
343 |
$24K |
| D7140 |
Extraction, erupted tooth or exposed root |
291 |
117 |
$19K |
| D0274 |
Bitewings - four radiographic images |
599 |
596 |
$16K |
| D1120 |
Prophylaxis - child |
445 |
444 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
702 |
699 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
280 |
278 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
568 |
565 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
123 |
110 |
$8K |
| D2331 |
|
83 |
64 |
$5K |
| D2330 |
|
95 |
57 |
$5K |
| D9110 |
|
153 |
152 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
324 |
318 |
$3K |