| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,152 |
2,029 |
$113K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,042 |
492 |
$100K |
| D1120 |
Prophylaxis - child |
2,422 |
2,267 |
$85K |
| D1206 |
Topical application of fluoride varnish |
4,367 |
4,090 |
$78K |
| D0140 |
Limited oral evaluation - problem focused |
1,297 |
1,215 |
$58K |
| D0274 |
Bitewings - four radiographic images |
1,295 |
1,195 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
1,292 |
1,203 |
$39K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
648 |
591 |
$38K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
345 |
231 |
$33K |
| D0220 |
Intraoral - periapical first radiographic image |
1,680 |
1,548 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
145 |
103 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,772 |
694 |
$13K |
| D1351 |
Sealant - per tooth |
522 |
131 |
$13K |
| D0330 |
Panoramic radiographic image |
415 |
403 |
$12K |
| D1354 |
|
270 |
89 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
40 |
40 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
113 |
103 |
$2K |
| D0272 |
Bitewings - two radiographic images |
67 |
65 |
$2K |
| D1330 |
|
140 |
135 |
$1K |
| D0270 |
|
12 |
12 |
$81.84 |
| D9986 |
|
85 |
84 |
$0.00 |