| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,307 |
1,277 |
$99K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,032 |
424 |
$98K |
| D0120 |
Periodic oral evaluation - established patient |
2,079 |
2,035 |
$58K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
604 |
299 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
568 |
555 |
$18K |
| D1120 |
Prophylaxis - child |
1,392 |
1,363 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,620 |
2,563 |
$7K |
| D1351 |
Sealant - per tooth |
2,606 |
665 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
216 |
116 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
78 |
42 |
$3K |
| D0274 |
Bitewings - four radiographic images |
1,407 |
1,373 |
$3K |
| D1330 |
|
2,676 |
2,619 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
2,475 |
2,409 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
132 |
130 |
$2K |
| D0272 |
Bitewings - two radiographic images |
790 |
772 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,333 |
2,243 |
$1K |
| D3120 |
|
265 |
133 |
$693.98 |
| D0602 |
|
39 |
39 |
$0.00 |
| D0601 |
|
77 |
76 |
$0.00 |
| D0603 |
|
12 |
12 |
$0.00 |