| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
875 |
866 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,357 |
1,344 |
$34K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
374 |
175 |
$33K |
| D1110 |
Prophylaxis - adult |
717 |
710 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,098 |
1,088 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
1,114 |
1,103 |
$16K |
| D0272 |
Bitewings - two radiographic images |
641 |
635 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
299 |
296 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,264 |
950 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
69 |
42 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
54 |
38 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
86 |
86 |
$4K |
| D1351 |
Sealant - per tooth |
107 |
26 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
45 |
45 |
$1K |
| D0190 |
|
12 |
12 |
$30.00 |
| D1999 |
|
21 |
18 |
$0.00 |