| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,171 |
2,063 |
$68K |
| D0120 |
Periodic oral evaluation - established patient |
2,926 |
2,783 |
$65K |
| D1110 |
Prophylaxis - adult |
1,383 |
1,306 |
$53K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,105 |
1,982 |
$39K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
556 |
305 |
$35K |
| D0274 |
Bitewings - four radiographic images |
1,251 |
1,173 |
$28K |
| D1206 |
Topical application of fluoride varnish |
977 |
954 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
354 |
184 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
356 |
331 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
413 |
385 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
869 |
290 |
$8K |
| D0272 |
Bitewings - two radiographic images |
459 |
429 |
$8K |
| D1351 |
Sealant - per tooth |
270 |
87 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
599 |
570 |
$7K |
| D0330 |
Panoramic radiographic image |
178 |
177 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
21 |
14 |
$1K |
| D1353 |
|
39 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
27 |
25 |
$536.80 |