| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,752 |
1,734 |
$86K |
| D0120 |
Periodic oral evaluation - established patient |
3,190 |
3,156 |
$85K |
| D1120 |
Prophylaxis - child |
1,272 |
1,264 |
$41K |
| D7140 |
Extraction, erupted tooth or exposed root |
466 |
217 |
$33K |
| D0272 |
Bitewings - two radiographic images |
1,070 |
1,058 |
$27K |
| D0330 |
Panoramic radiographic image |
386 |
375 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
459 |
277 |
$21K |
| D1206 |
Topical application of fluoride varnish |
1,434 |
1,423 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
170 |
100 |
$6K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
62 |
37 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
114 |
113 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
90 |
78 |
$3K |
| D2140 |
|
33 |
12 |
$2K |
| D1351 |
Sealant - per tooth |
31 |
12 |
$869.52 |