| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,233 |
3,233 |
$149K |
| D0120 |
Periodic oral evaluation - established patient |
4,370 |
4,370 |
$101K |
| D0274 |
Bitewings - four radiographic images |
3,648 |
3,648 |
$84K |
| D1120 |
Prophylaxis - child |
2,300 |
2,300 |
$78K |
| D0220 |
Intraoral - periapical first radiographic image |
5,824 |
5,788 |
$65K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,508 |
5,485 |
$62K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,406 |
678 |
$61K |
| D1351 |
Sealant - per tooth |
699 |
437 |
$53K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,296 |
687 |
$47K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,004 |
548 |
$47K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,709 |
3,709 |
$42K |
| D2140 |
|
666 |
347 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,051 |
1,051 |
$25K |
| D9990 |
|
532 |
510 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
545 |
291 |
$10K |
| D2160 |
|
241 |
124 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
334 |
326 |
$4K |
| D2330 |
|
65 |
36 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
1,298 |
1,287 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
27 |
27 |
$1K |