| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
428 |
412 |
$22K |
| D0330 |
Panoramic radiographic image |
306 |
292 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
621 |
606 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
763 |
744 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
344 |
327 |
$12K |
| D1120 |
Prophylaxis - child |
254 |
252 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
44 |
12 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
57 |
12 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
57 |
14 |
$5K |
| D2394 |
|
27 |
13 |
$4K |
| D0274 |
Bitewings - four radiographic images |
123 |
118 |
$4K |
| D1351 |
Sealant - per tooth |
116 |
25 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
70 |
64 |
$973.50 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
31 |
30 |
$959.00 |
| D9630 |
|
47 |
45 |
$688.00 |
| D0602 |
|
92 |
90 |
$129.00 |
| D1999 |
|
419 |
356 |
$0.00 |
| D0601 |
|
24 |
24 |
$0.00 |