| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
8,200 |
8,199 |
$470K |
| D0120 |
Periodic oral evaluation - established patient |
11,534 |
11,534 |
$326K |
| D1206 |
Topical application of fluoride varnish |
8,726 |
8,713 |
$240K |
| D1120 |
Prophylaxis - child |
3,423 |
3,423 |
$147K |
| D1351 |
Sealant - per tooth |
3,089 |
721 |
$129K |
| D0330 |
Panoramic radiographic image |
1,786 |
1,786 |
$70K |
| D2394 |
|
481 |
341 |
$66K |
| D0274 |
Bitewings - four radiographic images |
2,178 |
2,175 |
$61K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
441 |
367 |
$44K |
| D9999 |
Unspecified adjunctive procedure, by report |
375 |
375 |
$37K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,761 |
1,761 |
$24K |
| D0272 |
Bitewings - two radiographic images |
916 |
916 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
96 |
72 |
$8K |
| D4341 |
|
110 |
55 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
52 |
38 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
47 |
47 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
13 |
$935.00 |
| D0601 |
|
689 |
689 |
$686.00 |
| D9110 |
|
12 |
12 |
$336.00 |
| D0240 |
|
17 |
13 |
$281.00 |