| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,583 |
1,529 |
$59K |
| D7140 |
Extraction, erupted tooth or exposed root |
597 |
396 |
$39K |
| D0140 |
Limited oral evaluation - problem focused |
596 |
573 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
691 |
667 |
$13K |
| D0274 |
Bitewings - four radiographic images |
627 |
602 |
$13K |
| D0330 |
Panoramic radiographic image |
193 |
193 |
$12K |
| D1120 |
Prophylaxis - child |
349 |
335 |
$8K |
| D1206 |
Topical application of fluoride varnish |
291 |
283 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
284 |
269 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
405 |
392 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
88 |
86 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
12 |
$972.99 |
| D1351 |
Sealant - per tooth |
45 |
13 |
$814.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
12 |
$702.00 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$140.00 |
| D1999 |
|
328 |
292 |
$0.00 |
| D1330 |
|
287 |
258 |
$0.00 |