| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,029 |
3,010 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
3,134 |
3,112 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,128 |
2,116 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
880 |
679 |
$18K |
| D1120 |
Prophylaxis - child |
1,485 |
1,474 |
$14K |
| D1351 |
Sealant - per tooth |
516 |
66 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
624 |
620 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
533 |
397 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
1,032 |
1,021 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
3,366 |
3,310 |
$8K |
| D0274 |
Bitewings - four radiographic images |
1,612 |
1,600 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,582 |
1,571 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,054 |
2,643 |
$6K |
| D0272 |
Bitewings - two radiographic images |
695 |
684 |
$2K |
| D1206 |
Topical application of fluoride varnish |
88 |
88 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
63 |
38 |
$1K |
| D0601 |
|
109 |
105 |
$590.00 |
| D0603 |
|
109 |
109 |
$550.00 |
| D0602 |
|
14 |
14 |
$130.00 |