| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,618 |
1,556 |
$68K |
| D1206 |
Topical application of fluoride varnish |
2,212 |
2,120 |
$47K |
| D0120 |
Periodic oral evaluation - established patient |
1,586 |
1,515 |
$37K |
| D1351 |
Sealant - per tooth |
1,408 |
337 |
$33K |
| D0274 |
Bitewings - four radiographic images |
1,337 |
1,280 |
$32K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,432 |
1,338 |
$22K |
| D0330 |
Panoramic radiographic image |
732 |
686 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,622 |
1,553 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
281 |
213 |
$19K |
| D1120 |
Prophylaxis - child |
566 |
544 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
259 |
188 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
505 |
485 |
$14K |
| D2954 |
|
86 |
69 |
$13K |
| D4355 |
|
141 |
132 |
$10K |
| D4341 |
|
46 |
12 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
100 |
59 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
153 |
148 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
78 |
69 |
$2K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$206.55 |