| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,880 |
1,861 |
$104K |
| D0120 |
Periodic oral evaluation - established patient |
2,785 |
2,751 |
$97K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,369 |
848 |
$70K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
401 |
290 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
88 |
67 |
$10K |
| D1206 |
Topical application of fluoride varnish |
2,819 |
2,785 |
$7K |
| D0330 |
Panoramic radiographic image |
76 |
75 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
91 |
90 |
$5K |
| D1330 |
|
2,821 |
2,789 |
$3K |
| D1120 |
Prophylaxis - child |
1,012 |
996 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
2,670 |
2,611 |
$2K |
| D1351 |
Sealant - per tooth |
137 |
40 |
$2K |
| D0274 |
Bitewings - four radiographic images |
1,824 |
1,804 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,573 |
2,516 |
$628.66 |
| D7140 |
Extraction, erupted tooth or exposed root |
36 |
24 |
$567.64 |
| D0272 |
Bitewings - two radiographic images |
520 |
514 |
$100.55 |