| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,598 |
2,579 |
$88K |
| D9920 |
|
729 |
652 |
$82K |
| D0120 |
Periodic oral evaluation - established patient |
2,622 |
2,600 |
$55K |
| D0272 |
Bitewings - two radiographic images |
2,087 |
2,073 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
548 |
353 |
$31K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,434 |
2,385 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
2,683 |
2,619 |
$20K |
| D7140 |
Extraction, erupted tooth or exposed root |
240 |
133 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
204 |
163 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
243 |
135 |
$12K |
| D1351 |
Sealant - per tooth |
278 |
50 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
233 |
230 |
$4K |
| D0330 |
Panoramic radiographic image |
101 |
101 |
$4K |
| D2335 |
|
45 |
24 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
74 |
74 |
$2K |
| D9110 |
|
63 |
61 |
$2K |
| D1330 |
|
399 |
394 |
$2K |
| D2331 |
|
23 |
12 |
$1K |
| D1120 |
Prophylaxis - child |
15 |
15 |
$450.00 |
| D1999 |
|
673 |
624 |
$0.00 |