| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,726 |
4,723 |
$259K |
| D0120 |
Periodic oral evaluation - established patient |
5,080 |
5,074 |
$141K |
| D0274 |
Bitewings - four radiographic images |
3,361 |
3,359 |
$105K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,239 |
905 |
$101K |
| D1120 |
Prophylaxis - child |
1,307 |
1,305 |
$54K |
| D0330 |
Panoramic radiographic image |
826 |
826 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,242 |
2,239 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
851 |
851 |
$24K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
213 |
167 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
292 |
237 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
935 |
927 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
251 |
249 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
441 |
441 |
$7K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
50 |
30 |
$4K |
| D1351 |
Sealant - per tooth |
74 |
24 |
$3K |
| D2140 |
|
21 |
12 |
$1K |