| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
5,640 |
3,724 |
$281K |
| D0120 |
Periodic oral evaluation - established patient |
4,457 |
4,043 |
$138K |
| D1120 |
Prophylaxis - child |
2,563 |
1,925 |
$99K |
| D0330 |
Panoramic radiographic image |
2,056 |
1,441 |
$73K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,275 |
964 |
$36K |
| D0140 |
Limited oral evaluation - problem focused |
1,383 |
1,205 |
$33K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
472 |
348 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
278 |
221 |
$26K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,537 |
1,537 |
$21K |
| D0274 |
Bitewings - four radiographic images |
620 |
610 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
200 |
186 |
$11K |
| D0272 |
Bitewings - two radiographic images |
362 |
358 |
$6K |
| D1206 |
Topical application of fluoride varnish |
180 |
180 |
$5K |
| D5899 |
|
32 |
24 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
293 |
292 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
203 |
203 |
$4K |
| D9995 |
|
83 |
83 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
12 |
12 |
$1K |
| D0270 |
|
14 |
14 |
$196.00 |
| D0190 |
|
112 |
112 |
$0.00 |
| D4999 |
|
47 |
47 |
$0.00 |