| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,055 |
3,043 |
$128K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
737 |
492 |
$85K |
| D0120 |
Periodic oral evaluation - established patient |
3,126 |
3,114 |
$81K |
| D0210 |
Intraoral - complete series of radiographic images |
1,057 |
1,048 |
$58K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
912 |
910 |
$34K |
| D0140 |
Limited oral evaluation - problem focused |
1,208 |
1,183 |
$33K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
375 |
261 |
$33K |
| D0274 |
Bitewings - four radiographic images |
1,032 |
1,029 |
$31K |
| D0220 |
Intraoral - periapical first radiographic image |
2,618 |
2,559 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
825 |
825 |
$21K |
| D1120 |
Prophylaxis - child |
502 |
502 |
$21K |
| D1351 |
Sealant - per tooth |
525 |
57 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,218 |
1,908 |
$17K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
155 |
79 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
37 |
27 |
$2K |
| D2335 |
|
22 |
13 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
31 |
12 |
$1K |
| D4355 |
|
27 |
27 |
$1K |