| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,575 |
1,561 |
$66K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
367 |
187 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
1,248 |
1,239 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
546 |
430 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,295 |
1,286 |
$33K |
| D1206 |
Topical application of fluoride varnish |
929 |
921 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
554 |
435 |
$24K |
| D1351 |
Sealant - per tooth |
492 |
194 |
$23K |
| D0274 |
Bitewings - four radiographic images |
1,044 |
1,038 |
$19K |
| D1110 |
Prophylaxis - adult |
359 |
359 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
233 |
129 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
2,178 |
2,132 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
640 |
625 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,849 |
1,813 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
411 |
410 |
$11K |
| D0330 |
Panoramic radiographic image |
342 |
339 |
$8K |
| D0272 |
Bitewings - two radiographic images |
70 |
70 |
$731.84 |