| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,317 |
3,089 |
$115K |
| D0120 |
Periodic oral evaluation - established patient |
3,184 |
2,966 |
$74K |
| D8670 |
Periodic orthodontic treatment visit |
705 |
669 |
$64K |
| D9420 |
|
357 |
278 |
$32K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
181 |
39 |
$27K |
| D0160 |
|
366 |
340 |
$23K |
| D1206 |
Topical application of fluoride varnish |
1,578 |
1,420 |
$21K |
| D0330 |
Panoramic radiographic image |
758 |
650 |
$12K |
| D1120 |
Prophylaxis - child |
408 |
352 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
273 |
210 |
$8K |
| D0367 |
|
315 |
280 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
128 |
100 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
74 |
15 |
$4K |
| D4355 |
|
70 |
56 |
$4K |
| D1351 |
Sealant - per tooth |
125 |
28 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
46 |
44 |
$2K |
| D0170 |
|
14 |
13 |
$366.65 |
| D0340 |
|
23 |
12 |
$0.00 |