| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,713 |
1,708 |
$89K |
| D1120 |
Prophylaxis - child |
2,059 |
2,056 |
$85K |
| D0120 |
Periodic oral evaluation - established patient |
2,809 |
2,806 |
$79K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
894 |
530 |
$77K |
| D1351 |
Sealant - per tooth |
1,957 |
228 |
$62K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,635 |
2,628 |
$57K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,269 |
1,262 |
$52K |
| D0220 |
Intraoral - periapical first radiographic image |
2,041 |
2,011 |
$33K |
| D0330 |
Panoramic radiographic image |
414 |
414 |
$26K |
| D0274 |
Bitewings - four radiographic images |
685 |
682 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
167 |
130 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,965 |
1,611 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
235 |
229 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
141 |
77 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
268 |
266 |
$12K |
| D0272 |
Bitewings - two radiographic images |
399 |
396 |
$8K |
| D1206 |
Topical application of fluoride varnish |
262 |
261 |
$7K |
| D1999 |
|
139 |
87 |
$0.00 |