| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,041 |
1,796 |
$45K |
| D1206 |
Topical application of fluoride varnish |
3,266 |
2,855 |
$44K |
| D0210 |
Intraoral - complete series of radiographic images |
793 |
754 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
1,926 |
1,612 |
$31K |
| D1110 |
Prophylaxis - adult |
855 |
786 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,234 |
1,087 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
271 |
177 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
291 |
184 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
696 |
612 |
$15K |
| D0274 |
Bitewings - four radiographic images |
529 |
478 |
$12K |
| D1351 |
Sealant - per tooth |
574 |
91 |
$10K |
| D2940 |
|
281 |
173 |
$10K |
| D0330 |
Panoramic radiographic image |
309 |
266 |
$10K |
| D1354 |
|
1,110 |
262 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
651 |
573 |
$6K |
| D4346 |
|
65 |
52 |
$5K |
| D0272 |
Bitewings - two radiographic images |
200 |
199 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
63 |
38 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
13 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
224 |
124 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
29 |
14 |
$880.76 |
| D0270 |
|
42 |
42 |
$433.74 |
| D1330 |
|
1,231 |
1,188 |
$0.00 |