| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,625 |
2,557 |
$107K |
| D1120 |
Prophylaxis - child |
2,282 |
2,229 |
$101K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,603 |
2,531 |
$66K |
| D0120 |
Periodic oral evaluation - established patient |
3,216 |
3,141 |
$64K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,033 |
653 |
$57K |
| D0274 |
Bitewings - four radiographic images |
2,173 |
2,124 |
$53K |
| D0330 |
Panoramic radiographic image |
1,457 |
1,423 |
$51K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,989 |
2,922 |
$45K |
| D0210 |
Intraoral - complete series of radiographic images |
744 |
699 |
$42K |
| D0140 |
Limited oral evaluation - problem focused |
1,238 |
1,202 |
$37K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,658 |
2,448 |
$30K |
| D0220 |
Intraoral - periapical first radiographic image |
3,526 |
3,394 |
$26K |
| D7140 |
Extraction, erupted tooth or exposed root |
641 |
238 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
379 |
285 |
$16K |
| D1206 |
Topical application of fluoride varnish |
493 |
478 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
91 |
65 |
$6K |
| D0272 |
Bitewings - two radiographic images |
203 |
199 |
$3K |
| D4341 |
|
32 |
12 |
$2K |
| D1351 |
Sealant - per tooth |
54 |
14 |
$1K |
| D2332 |
|
16 |
13 |
$989.91 |
| D9986 |
|
1,307 |
1,065 |
$0.00 |
| D9987 |
|
157 |
135 |
$0.00 |