| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,989 |
2,748 |
$137K |
| D0274 |
Bitewings - four radiographic images |
2,822 |
2,578 |
$72K |
| D0120 |
Periodic oral evaluation - established patient |
3,277 |
3,025 |
$72K |
| D0230 |
Intraoral - periapical each additional radiographic image |
10,253 |
3,311 |
$63K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,269 |
3,921 |
$52K |
| D0220 |
Intraoral - periapical first radiographic image |
3,939 |
3,553 |
$39K |
| D1120 |
Prophylaxis - child |
1,131 |
1,049 |
$35K |
| D1351 |
Sealant - per tooth |
2,251 |
300 |
$35K |
| D0330 |
Panoramic radiographic image |
954 |
859 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
396 |
170 |
$22K |
| D0145 |
Oral evaluation for a patient under three years of age |
184 |
167 |
$21K |
| D1330 |
|
9,441 |
7,566 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
578 |
509 |
$14K |
| D9430 |
|
388 |
325 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
62 |
39 |
$5K |
| D0272 |
Bitewings - two radiographic images |
233 |
207 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
71 |
36 |
$3K |
| D0240 |
|
314 |
147 |
$2K |
| D1206 |
Topical application of fluoride varnish |
744 |
229 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
236 |
216 |
$2K |
| D0180 |
|
49 |
46 |
$1K |
| D1354 |
|
284 |
121 |
$302.98 |
| D0603 |
|
8,334 |
6,675 |
$0.15 |
| D0601 |
|
455 |
424 |
$0.00 |
| D0602 |
|
12 |
12 |
$0.00 |
| D1999 |
|
5,071 |
4,199 |
$0.00 |