| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
905 |
904 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,116 |
1,115 |
$32K |
| D1208 |
Topical application of fluoride, excluding varnish |
886 |
885 |
$24K |
| D1351 |
Sealant - per tooth |
322 |
163 |
$19K |
| D0274 |
Bitewings - four radiographic images |
784 |
783 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
235 |
205 |
$14K |
| D1110 |
Prophylaxis - adult |
266 |
266 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
467 |
467 |
$12K |
| D0330 |
Panoramic radiographic image |
356 |
355 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
140 |
86 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
91 |
78 |
$8K |
| D4341 |
|
57 |
31 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
150 |
130 |
$6K |
| D9110 |
|
113 |
113 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
443 |
443 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
550 |
549 |
$4K |
| D0272 |
Bitewings - two radiographic images |
269 |
269 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
28 |
16 |
$2K |
| D2950 |
|
21 |
17 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$210.32 |