| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,836 |
3,829 |
$47K |
| D4341 |
|
802 |
356 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
3,349 |
3,338 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,262 |
775 |
$19K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
506 |
306 |
$17K |
| D0330 |
Panoramic radiographic image |
1,205 |
1,202 |
$17K |
| D0274 |
Bitewings - four radiographic images |
3,449 |
3,435 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
868 |
853 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
523 |
260 |
$10K |
| D0180 |
|
445 |
441 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
907 |
906 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
4,670 |
4,615 |
$7K |
| D1120 |
Prophylaxis - child |
520 |
520 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
110 |
73 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,808 |
3,794 |
$3K |
| D1351 |
Sealant - per tooth |
176 |
27 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
465 |
465 |
$1K |
| D2330 |
|
30 |
12 |
$775.00 |
| D7230 |
|
27 |
12 |
$210.00 |
| D9310 |
|
43 |
43 |
$197.50 |
| D9210 |
|
16 |
14 |
$130.00 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$117.00 |