| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,442 |
2,393 |
$134K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,018 |
587 |
$127K |
| D1120 |
Prophylaxis - child |
2,429 |
2,398 |
$107K |
| D0120 |
Periodic oral evaluation - established patient |
3,563 |
3,504 |
$101K |
| D1206 |
Topical application of fluoride varnish |
3,761 |
3,716 |
$94K |
| D1351 |
Sealant - per tooth |
2,149 |
431 |
$74K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,222 |
1,203 |
$59K |
| D0274 |
Bitewings - four radiographic images |
2,471 |
2,428 |
$53K |
| D0330 |
Panoramic radiographic image |
842 |
833 |
$36K |
| D0140 |
Limited oral evaluation - problem focused |
707 |
692 |
$28K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
156 |
98 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
636 |
628 |
$14K |
| D0272 |
Bitewings - two radiographic images |
622 |
617 |
$10K |
| D1330 |
|
1,288 |
1,278 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
301 |
288 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
23 |
13 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
31 |
13 |
$2K |