| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
5,725 |
5,724 |
$312K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,057 |
2,255 |
$290K |
| D0120 |
Periodic oral evaluation - established patient |
7,947 |
7,947 |
$217K |
| D0274 |
Bitewings - four radiographic images |
4,451 |
4,450 |
$132K |
| D1120 |
Prophylaxis - child |
2,726 |
2,725 |
$113K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,501 |
1,171 |
$88K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
781 |
626 |
$80K |
| D0330 |
Panoramic radiographic image |
1,479 |
1,478 |
$64K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,453 |
3,453 |
$48K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,199 |
1,198 |
$34K |
| D1351 |
Sealant - per tooth |
406 |
163 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,179 |
1,147 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
524 |
515 |
$11K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
134 |
90 |
$10K |
| D1206 |
Topical application of fluoride varnish |
239 |
239 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
110 |
50 |
$6K |
| D2331 |
|
33 |
25 |
$3K |
| D2335 |
|
16 |
13 |
$3K |
| D2140 |
|
39 |
32 |
$2K |
| D2160 |
|
20 |
17 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
12 |
12 |
$2K |
| D9110 |
|
38 |
37 |
$985.06 |
| D0350 |
|
113 |
113 |
$857.22 |
| D0230 |
Intraoral - periapical each additional radiographic image |
65 |
64 |
$697.56 |
| D0140 |
Limited oral evaluation - problem focused |
42 |
41 |
$649.30 |