| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
676 |
604 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
853 |
717 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
388 |
355 |
$10K |
| D1110 |
Prophylaxis - adult |
232 |
216 |
$9K |
| D0274 |
Bitewings - four radiographic images |
566 |
509 |
$9K |
| D1351 |
Sealant - per tooth |
99 |
65 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
377 |
351 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
1,104 |
963 |
$7K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
77 |
71 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
86 |
69 |
$5K |
| D4341 |
|
21 |
12 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
270 |
251 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
876 |
753 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
58 |
50 |
$4K |
| D1206 |
Topical application of fluoride varnish |
155 |
135 |
$3K |
| D0330 |
Panoramic radiographic image |
85 |
83 |
$2K |
| D0270 |
|
221 |
167 |
$1K |
| D0272 |
Bitewings - two radiographic images |
131 |
107 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
36 |
36 |
$522.60 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
14 |
$493.60 |