| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,133 |
1,126 |
$47K |
| D1351 |
Sealant - per tooth |
921 |
381 |
$47K |
| D0120 |
Periodic oral evaluation - established patient |
1,301 |
1,296 |
$36K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,088 |
1,082 |
$29K |
| D1110 |
Prophylaxis - adult |
546 |
543 |
$26K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
422 |
324 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
858 |
850 |
$22K |
| D0274 |
Bitewings - four radiographic images |
1,077 |
1,068 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
404 |
306 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,684 |
1,662 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,919 |
1,509 |
$10K |
| D4341 |
|
60 |
33 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
118 |
74 |
$7K |
| D0272 |
Bitewings - two radiographic images |
246 |
246 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
122 |
120 |
$2K |
| D2331 |
|
21 |
12 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
123 |
123 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
17 |
$2K |