| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,314 |
2,311 |
$113K |
| D1110 |
Prophylaxis - adult |
1,400 |
1,400 |
$93K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,085 |
804 |
$91K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,065 |
1,065 |
$87K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
968 |
777 |
$54K |
| D1120 |
Prophylaxis - child |
2,358 |
2,354 |
$50K |
| D1351 |
Sealant - per tooth |
2,794 |
813 |
$44K |
| D1206 |
Topical application of fluoride varnish |
3,698 |
3,695 |
$22K |
| D9999 |
Unspecified adjunctive procedure, by report |
364 |
364 |
$8K |
| D0272 |
Bitewings - two radiographic images |
1,630 |
1,625 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
507 |
494 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
52 |
37 |
$6K |
| D0274 |
Bitewings - four radiographic images |
863 |
863 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
2,606 |
2,555 |
$5K |
| D1330 |
|
3,822 |
3,819 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,168 |
2,115 |
$3K |
| D0191 |
|
384 |
382 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
13 |
12 |
$840.62 |
| D9986 |
|
744 |
730 |
$0.00 |