| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,725 |
2,698 |
$106K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,815 |
3,769 |
$76K |
| D0120 |
Periodic oral evaluation - established patient |
3,622 |
3,589 |
$60K |
| D1120 |
Prophylaxis - child |
1,886 |
1,865 |
$55K |
| D0210 |
Intraoral - complete series of radiographic images |
1,413 |
678 |
$41K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
453 |
335 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
851 |
834 |
$24K |
| D0274 |
Bitewings - four radiographic images |
1,040 |
1,017 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
2,035 |
1,983 |
$18K |
| D1351 |
Sealant - per tooth |
627 |
229 |
$17K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
107 |
80 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,452 |
1,343 |
$13K |
| D9630 |
|
777 |
772 |
$11K |
| D0330 |
Panoramic radiographic image |
206 |
200 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
46 |
12 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
203 |
197 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
33 |
25 |
$3K |
| D0272 |
Bitewings - two radiographic images |
56 |
56 |
$1K |
| D1206 |
Topical application of fluoride varnish |
433 |
433 |
$567.63 |
| D7140 |
Extraction, erupted tooth or exposed root |
29 |
12 |
$0.00 |