| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,382 |
4,380 |
$237K |
| D0120 |
Periodic oral evaluation - established patient |
4,544 |
4,540 |
$123K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,596 |
1,159 |
$98K |
| D0274 |
Bitewings - four radiographic images |
2,965 |
2,964 |
$80K |
| D1120 |
Prophylaxis - child |
1,760 |
1,760 |
$74K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
667 |
604 |
$61K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,888 |
1,887 |
$55K |
| D0220 |
Intraoral - periapical first radiographic image |
3,642 |
3,605 |
$48K |
| D1206 |
Topical application of fluoride varnish |
1,239 |
1,238 |
$37K |
| D2394 |
|
226 |
195 |
$32K |
| D7140 |
Extraction, erupted tooth or exposed root |
412 |
332 |
$24K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
209 |
188 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,295 |
2,235 |
$22K |
| D0272 |
Bitewings - two radiographic images |
1,149 |
1,148 |
$18K |
| D2750 |
|
26 |
24 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,256 |
1,256 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
310 |
309 |
$15K |
| D9110 |
|
439 |
438 |
$12K |
| D1351 |
Sealant - per tooth |
35 |
12 |
$1K |
| D9990 |
|
33 |
30 |
$715.00 |