| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,895 |
1,877 |
$115K |
| D1120 |
Prophylaxis - child |
1,690 |
1,679 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
3,290 |
3,263 |
$47K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
669 |
358 |
$37K |
| D0330 |
Panoramic radiographic image |
441 |
441 |
$33K |
| D0274 |
Bitewings - four radiographic images |
1,954 |
1,936 |
$19K |
| D1351 |
Sealant - per tooth |
2,839 |
775 |
$13K |
| D1330 |
|
3,654 |
3,625 |
$10K |
| D0272 |
Bitewings - two radiographic images |
1,362 |
1,354 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
60 |
60 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
66 |
31 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
122 |
122 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
3,597 |
3,552 |
$962.72 |
| D1208 |
Topical application of fluoride, excluding varnish |
3,630 |
3,599 |
$818.53 |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,487 |
3,431 |
$541.09 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
101 |
69 |
$516.25 |
| D2332 |
|
14 |
12 |
$0.00 |
| D7111 |
|
36 |
19 |
$0.00 |
| D0240 |
|
28 |
28 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
17 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
30 |
30 |
$0.00 |