| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,427 |
2,427 |
$138K |
| D0274 |
Bitewings - four radiographic images |
2,555 |
2,555 |
$90K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,140 |
652 |
$89K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,921 |
1,921 |
$56K |
| D0120 |
Periodic oral evaluation - established patient |
1,743 |
1,743 |
$51K |
| D1120 |
Prophylaxis - child |
1,213 |
1,212 |
$51K |
| D0330 |
Panoramic radiographic image |
1,269 |
1,269 |
$50K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
335 |
244 |
$33K |
| D1206 |
Topical application of fluoride varnish |
842 |
842 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
316 |
189 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
643 |
642 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
475 |
469 |
$7K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
73 |
40 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
182 |
182 |
$3K |
| D1351 |
Sealant - per tooth |
65 |
13 |
$2K |
| D2332 |
|
18 |
15 |
$2K |
| D0272 |
Bitewings - two radiographic images |
90 |
90 |
$2K |
| D2331 |
|
19 |
16 |
$2K |
| D2330 |
|
23 |
12 |
$1K |
| D1999 |
|
42 |
42 |
$0.00 |