| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,391 |
2,112 |
$125K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,518 |
916 |
$123K |
| D0120 |
Periodic oral evaluation - established patient |
2,875 |
2,601 |
$70K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
941 |
550 |
$60K |
| D0274 |
Bitewings - four radiographic images |
1,410 |
1,286 |
$50K |
| D1206 |
Topical application of fluoride varnish |
1,815 |
1,648 |
$40K |
| D1120 |
Prophylaxis - child |
1,074 |
1,004 |
$36K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
314 |
230 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
658 |
583 |
$26K |
| D7140 |
Extraction, erupted tooth or exposed root |
207 |
78 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
357 |
326 |
$14K |
| D0272 |
Bitewings - two radiographic images |
544 |
506 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
443 |
398 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
89 |
83 |
$5K |
| D1351 |
Sealant - per tooth |
187 |
60 |
$5K |
| D0330 |
Panoramic radiographic image |
61 |
57 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
113 |
67 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
27 |
12 |
$171.00 |