| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,447 |
1,342 |
$55K |
| D4341 |
|
182 |
96 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
1,210 |
1,127 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
937 |
894 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
386 |
281 |
$23K |
| D1351 |
Sealant - per tooth |
312 |
187 |
$18K |
| D0274 |
Bitewings - four radiographic images |
875 |
782 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
468 |
402 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,615 |
1,470 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
213 |
157 |
$7K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
89 |
51 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,566 |
1,426 |
$5K |
| D0330 |
Panoramic radiographic image |
177 |
156 |
$3K |
| D8670 |
Periodic orthodontic treatment visit |
12 |
12 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
56 |
39 |
$3K |
| D9110 |
|
27 |
24 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
90 |
59 |
$1K |
| D1110 |
Prophylaxis - adult |
33 |
25 |
$943.00 |
| D0140 |
Limited oral evaluation - problem focused |
38 |
38 |
$615.60 |