| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
6,455 |
6,453 |
$243K |
| D0120 |
Periodic oral evaluation - established patient |
7,762 |
7,762 |
$158K |
| D0210 |
Intraoral - complete series of radiographic images |
4,944 |
4,929 |
$146K |
| D0220 |
Intraoral - periapical first radiographic image |
5,041 |
5,027 |
$50K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,643 |
4,642 |
$45K |
| D0274 |
Bitewings - four radiographic images |
1,885 |
1,885 |
$40K |
| D2750 |
|
81 |
66 |
$37K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
491 |
390 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,689 |
1,689 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
283 |
242 |
$17K |
| D1351 |
Sealant - per tooth |
179 |
67 |
$9K |
| D2394 |
|
93 |
82 |
$7K |
| D2954 |
|
62 |
51 |
$7K |
| D1120 |
Prophylaxis - child |
233 |
233 |
$7K |
| D2335 |
|
46 |
36 |
$5K |
| D2332 |
|
54 |
48 |
$4K |
| D3320 |
|
17 |
12 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
107 |
107 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
27 |
25 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
129 |
127 |
$1K |
| D2331 |
|
20 |
17 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
14 |
$614.20 |