| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
12,995 |
12,988 |
$555K |
| D0120 |
Periodic oral evaluation - established patient |
18,758 |
18,746 |
$417K |
| D1120 |
Prophylaxis - child |
6,509 |
6,504 |
$219K |
| D1208 |
Topical application of fluoride, excluding varnish |
13,360 |
13,349 |
$154K |
| D1351 |
Sealant - per tooth |
2,071 |
1,329 |
$141K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,088 |
862 |
$92K |
| D0220 |
Intraoral - periapical first radiographic image |
7,890 |
7,875 |
$82K |
| D0272 |
Bitewings - two radiographic images |
6,416 |
6,416 |
$82K |
| D0330 |
Panoramic radiographic image |
2,255 |
2,255 |
$74K |
| D0274 |
Bitewings - four radiographic images |
2,534 |
2,533 |
$55K |
| D7140 |
Extraction, erupted tooth or exposed root |
942 |
844 |
$49K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,851 |
7,844 |
$46K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
530 |
447 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
587 |
587 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
236 |
236 |
$2K |
| D4341 |
|
22 |
13 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
33 |
29 |
$2K |
| D9110 |
|
12 |
12 |
$251.10 |
| D0602 |
|
28 |
28 |
$28.00 |