| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,829 |
3,699 |
$160K |
| D1206 |
Topical application of fluoride varnish |
5,502 |
5,326 |
$112K |
| D0120 |
Periodic oral evaluation - established patient |
4,141 |
4,007 |
$97K |
| D0274 |
Bitewings - four radiographic images |
3,631 |
3,516 |
$89K |
| D1351 |
Sealant - per tooth |
2,366 |
664 |
$68K |
| D0330 |
Panoramic radiographic image |
1,659 |
1,593 |
$62K |
| D1120 |
Prophylaxis - child |
1,640 |
1,600 |
$54K |
| D0220 |
Intraoral - periapical first radiographic image |
4,107 |
3,890 |
$49K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
830 |
574 |
$48K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
666 |
488 |
$46K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,493 |
3,233 |
$41K |
| D4355 |
|
345 |
337 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
920 |
892 |
$26K |
| D7140 |
Extraction, erupted tooth or exposed root |
143 |
100 |
$9K |
| D2954 |
|
35 |
26 |
$6K |
| D0272 |
Bitewings - two radiographic images |
182 |
174 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
114 |
104 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
74 |
73 |
$2K |
| D4346 |
|
12 |
12 |
$526.56 |