| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
559 |
553 |
$32K |
| D1120 |
Prophylaxis - child |
755 |
751 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
1,013 |
1,009 |
$29K |
| D1206 |
Topical application of fluoride varnish |
942 |
937 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
338 |
332 |
$17K |
| D1351 |
Sealant - per tooth |
515 |
79 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
95 |
52 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
368 |
365 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
83 |
53 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
707 |
688 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
51 |
27 |
$5K |
| D1330 |
|
716 |
711 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
620 |
609 |
$4K |
| D0274 |
Bitewings - four radiographic images |
136 |
132 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
49 |
46 |
$3K |
| D0272 |
Bitewings - two radiographic images |
123 |
123 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$561.60 |