| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,726 |
2,674 |
$150K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,496 |
4,430 |
$104K |
| D0120 |
Periodic oral evaluation - established patient |
3,641 |
3,587 |
$102K |
| D1351 |
Sealant - per tooth |
3,073 |
545 |
$102K |
| D1120 |
Prophylaxis - child |
2,212 |
2,176 |
$96K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
398 |
144 |
$65K |
| D0330 |
Panoramic radiographic image |
1,511 |
1,475 |
$65K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,158 |
1,133 |
$57K |
| D0272 |
Bitewings - two radiographic images |
2,578 |
2,539 |
$39K |
| D0274 |
Bitewings - four radiographic images |
1,159 |
1,137 |
$24K |
| D0140 |
Limited oral evaluation - problem focused |
450 |
405 |
$18K |
| D3110 |
|
445 |
146 |
$6K |
| D1330 |
|
410 |
402 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
15 |
12 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$380.00 |