| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,636 |
3,636 |
$122K |
| D1120 |
Prophylaxis - child |
3,024 |
3,023 |
$97K |
| D1351 |
Sealant - per tooth |
2,678 |
588 |
$86K |
| D0330 |
Panoramic radiographic image |
3,805 |
3,804 |
$80K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,474 |
3,473 |
$71K |
| D0120 |
Periodic oral evaluation - established patient |
3,482 |
3,482 |
$68K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,022 |
3,022 |
$35K |
| D0272 |
Bitewings - two radiographic images |
1,540 |
1,539 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,332 |
1,330 |
$13K |
| D1206 |
Topical application of fluoride varnish |
556 |
556 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
217 |
161 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
957 |
954 |
$10K |
| D0274 |
Bitewings - four radiographic images |
430 |
430 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
701 |
701 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
151 |
119 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,068 |
1,064 |
$6K |
| D0350 |
|
478 |
478 |
$3K |
| D8660 |
|
44 |
44 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
17 |
12 |
$555.54 |
| D9110 |
|
39 |
39 |
$390.40 |
| D0601 |
|
133 |
133 |
$133.00 |
| D0270 |
|
12 |
12 |
$59.85 |
| D1330 |
|
742 |
742 |
$0.00 |