| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
760 |
756 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
800 |
794 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
299 |
199 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
324 |
190 |
$16K |
| D0272 |
Bitewings - two radiographic images |
1,003 |
994 |
$16K |
| D1120 |
Prophylaxis - child |
333 |
327 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
1,134 |
1,119 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,083 |
1,071 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
340 |
335 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
430 |
425 |
$8K |
| D1351 |
Sealant - per tooth |
215 |
45 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
40 |
18 |
$3K |
| D9110 |
|
18 |
18 |
$580.00 |
| D1999 |
|
75 |
71 |
$0.00 |