| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,262 |
4,260 |
$160K |
| D0120 |
Periodic oral evaluation - established patient |
6,539 |
6,537 |
$133K |
| D1120 |
Prophylaxis - child |
2,916 |
2,916 |
$98K |
| D0274 |
Bitewings - four radiographic images |
4,478 |
4,474 |
$85K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,512 |
6,444 |
$77K |
| D0220 |
Intraoral - periapical first radiographic image |
6,992 |
6,942 |
$53K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,869 |
4,867 |
$42K |
| D0210 |
Intraoral - complete series of radiographic images |
1,601 |
1,597 |
$28K |
| D0140 |
Limited oral evaluation - problem focused |
2,737 |
2,516 |
$27K |
| D9999 |
Unspecified adjunctive procedure, by report |
235 |
235 |
$23K |
| D1206 |
Topical application of fluoride varnish |
952 |
952 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
690 |
690 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
246 |
176 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
261 |
171 |
$14K |
| D1351 |
Sealant - per tooth |
339 |
79 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
133 |
91 |
$5K |
| D1999 |
|
65 |
65 |
$1K |
| D0601 |
|
1,318 |
1,234 |
$744.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
13 |
$643.42 |
| D0603 |
|
20 |
20 |
$15.00 |
| D0602 |
|
17 |
17 |
$13.00 |