| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,124 |
1,562 |
$97K |
| D0140 |
Limited oral evaluation - problem focused |
1,703 |
1,173 |
$67K |
| D0120 |
Periodic oral evaluation - established patient |
2,423 |
1,866 |
$52K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,439 |
1,025 |
$51K |
| D0210 |
Intraoral - complete series of radiographic images |
611 |
414 |
$39K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,922 |
1,514 |
$38K |
| D0274 |
Bitewings - four radiographic images |
1,076 |
797 |
$31K |
| D1120 |
Prophylaxis - child |
902 |
670 |
$27K |
| D0330 |
Panoramic radiographic image |
466 |
314 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,310 |
874 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
240 |
120 |
$18K |
| D1351 |
Sealant - per tooth |
736 |
76 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
167 |
60 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
209 |
89 |
$12K |
| D0272 |
Bitewings - two radiographic images |
213 |
132 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
18 |
14 |
$3K |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$267.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
20 |
12 |
$194.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
4,318 |
3,028 |
$0.00 |