| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
782 |
749 |
$48K |
| D1351 |
Sealant - per tooth |
1,340 |
193 |
$35K |
| D1206 |
Topical application of fluoride varnish |
1,655 |
1,581 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
546 |
522 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
261 |
172 |
$30K |
| D1120 |
Prophylaxis - child |
500 |
482 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
211 |
125 |
$20K |
| D0274 |
Bitewings - four radiographic images |
460 |
436 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
581 |
543 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
346 |
318 |
$15K |
| D0330 |
Panoramic radiographic image |
161 |
148 |
$11K |
| D1354 |
|
454 |
103 |
$10K |
| D0190 |
|
498 |
493 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
40 |
39 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
217 |
192 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
28 |
13 |
$3K |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$210.00 |