| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,872 |
1,853 |
$60K |
| D0210 |
Intraoral - complete series of radiographic images |
928 |
922 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
1,726 |
1,716 |
$30K |
| D0140 |
Limited oral evaluation - problem focused |
616 |
581 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,177 |
1,165 |
$17K |
| D1120 |
Prophylaxis - child |
384 |
383 |
$12K |
| D1206 |
Topical application of fluoride varnish |
484 |
481 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
2,410 |
2,345 |
$9K |
| D0274 |
Bitewings - four radiographic images |
1,129 |
1,120 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,090 |
1,697 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
63 |
40 |
$3K |
| D0180 |
|
39 |
39 |
$2K |
| D0330 |
Panoramic radiographic image |
151 |
148 |
$1K |
| D1351 |
Sealant - per tooth |
107 |
18 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
22 |
13 |
$600.00 |
| D0270 |
|
38 |
38 |
$60.00 |
| D1999 |
|
1,299 |
1,140 |
$0.00 |