| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,496 |
3,386 |
$221K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,704 |
626 |
$177K |
| D1206 |
Topical application of fluoride varnish |
6,835 |
6,498 |
$171K |
| D0120 |
Periodic oral evaluation - established patient |
4,728 |
4,555 |
$143K |
| D1120 |
Prophylaxis - child |
2,981 |
2,852 |
$132K |
| D0330 |
Panoramic radiographic image |
2,481 |
2,419 |
$114K |
| D7140 |
Extraction, erupted tooth or exposed root |
933 |
578 |
$114K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,505 |
1,446 |
$83K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
616 |
371 |
$83K |
| D0272 |
Bitewings - two radiographic images |
2,517 |
2,429 |
$43K |
| D1351 |
Sealant - per tooth |
1,080 |
107 |
$37K |
| D0140 |
Limited oral evaluation - problem focused |
783 |
771 |
$36K |
| D1330 |
|
2,370 |
2,248 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
60 |
52 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
421 |
412 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
117 |
117 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
26 |
25 |
$184.32 |