| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,071 |
886 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
488 |
326 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
969 |
814 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
678 |
368 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
735 |
253 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
878 |
692 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
480 |
349 |
$6K |
| D1120 |
Prophylaxis - child |
421 |
377 |
$2K |
| D1206 |
Topical application of fluoride varnish |
1,424 |
1,196 |
$824.86 |
| D0272 |
Bitewings - two radiographic images |
228 |
197 |
$530.23 |
| D1351 |
Sealant - per tooth |
38 |
12 |
$398.28 |
| D0274 |
Bitewings - four radiographic images |
197 |
161 |
$49.00 |
| D0220 |
Intraoral - periapical first radiographic image |
77 |
61 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
52 |
38 |
$0.00 |
| D2331 |
|
32 |
12 |
$0.00 |