| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
763 |
750 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
803 |
783 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
622 |
610 |
$15K |
| D1351 |
Sealant - per tooth |
105 |
62 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
325 |
313 |
$7K |
| D0274 |
Bitewings - four radiographic images |
381 |
372 |
$6K |
| D1110 |
Prophylaxis - adult |
128 |
124 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
872 |
829 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
800 |
746 |
$4K |
| D1206 |
Topical application of fluoride varnish |
115 |
114 |
$3K |
| D4342 |
|
18 |
12 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
115 |
106 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
32 |
27 |
$2K |
| D0330 |
Panoramic radiographic image |
69 |
64 |
$1K |
| D0272 |
Bitewings - two radiographic images |
123 |
121 |
$987.00 |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
13 |
12 |
$818.55 |
| D7140 |
Extraction, erupted tooth or exposed root |
17 |
14 |
$704.16 |
| D0140 |
Limited oral evaluation - problem focused |
28 |
26 |
$453.60 |
| D0601 |
|
52 |
52 |
$15.00 |
| D0602 |
|
33 |
32 |
$9.00 |