| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
843 |
819 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
783 |
761 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
163 |
91 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
339 |
332 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
171 |
134 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
202 |
200 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
388 |
371 |
$5K |
| D0274 |
Bitewings - four radiographic images |
545 |
522 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
132 |
102 |
$4K |
| D1120 |
Prophylaxis - child |
168 |
164 |
$4K |
| D0330 |
Panoramic radiographic image |
116 |
115 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
379 |
367 |
$2K |
| D1351 |
Sealant - per tooth |
124 |
54 |
$2K |
| D1206 |
Topical application of fluoride varnish |
133 |
122 |
$1K |
| D0601 |
|
310 |
300 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
76 |
75 |
$608.00 |
| D1354 |
|
140 |
68 |
$500.00 |
| D0603 |
|
72 |
70 |
$318.00 |
| D0270 |
|
41 |
38 |
$150.00 |
| D1999 |
|
16 |
15 |
$91.00 |
| D0191 |
|
12 |
12 |
$0.00 |
| D1330 |
|
14 |
14 |
$0.00 |