| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,261 |
1,184 |
$47K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
487 |
332 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
1,073 |
999 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,139 |
1,032 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
668 |
610 |
$17K |
| D0330 |
Panoramic radiographic image |
793 |
724 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
211 |
123 |
$14K |
| D0274 |
Bitewings - four radiographic images |
633 |
588 |
$9K |
| D1206 |
Topical application of fluoride varnish |
407 |
405 |
$9K |
| D1110 |
Prophylaxis - adult |
170 |
152 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
393 |
299 |
$7K |
| D1351 |
Sealant - per tooth |
108 |
56 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
140 |
76 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
1,022 |
911 |
$5K |
| D4341 |
|
28 |
12 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
294 |
279 |
$5K |
| D0272 |
Bitewings - two radiographic images |
513 |
449 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
35 |
24 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
607 |
434 |
$2K |
| D2950 |
|
31 |
28 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
22 |
13 |
$1K |