| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,041 |
1,984 |
$80K |
| D1120 |
Prophylaxis - child |
1,516 |
1,469 |
$67K |
| D0120 |
Periodic oral evaluation - established patient |
2,705 |
2,623 |
$47K |
| D1206 |
Topical application of fluoride varnish |
2,432 |
2,365 |
$34K |
| D0274 |
Bitewings - four radiographic images |
1,091 |
1,043 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
943 |
897 |
$23K |
| D0330 |
Panoramic radiographic image |
560 |
543 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
366 |
219 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
306 |
270 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
406 |
358 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
67 |
46 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
38 |
25 |
$2K |
| D0272 |
Bitewings - two radiographic images |
107 |
100 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
22 |
13 |
$843.60 |
| D1351 |
Sealant - per tooth |
43 |
12 |
$655.36 |
| D0190 |
|
18 |
18 |
$486.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
39 |
27 |
$252.90 |
| D9986 |
|
848 |
718 |
$0.00 |