| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,620 |
1,371 |
$44K |
| D1120 |
Prophylaxis - child |
1,099 |
979 |
$43K |
| D1110 |
Prophylaxis - adult |
953 |
856 |
$38K |
| D1351 |
Sealant - per tooth |
487 |
264 |
$35K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,026 |
913 |
$26K |
| D0274 |
Bitewings - four radiographic images |
1,639 |
1,411 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,038 |
920 |
$22K |
| D7140 |
Extraction, erupted tooth or exposed root |
363 |
206 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
2,511 |
2,150 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,229 |
1,909 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
501 |
438 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
238 |
167 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
412 |
370 |
$6K |
| D4342 |
|
67 |
45 |
$5K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
16 |
13 |
$4K |
| D4341 |
|
34 |
12 |
$4K |
| D2330 |
|
69 |
48 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
33 |
25 |
$2K |
| D0272 |
Bitewings - two radiographic images |
209 |
187 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
35 |
25 |
$2K |
| D2331 |
|
26 |
16 |
$2K |
| D0270 |
|
54 |
54 |
$296.80 |
| D2940 |
|
14 |
12 |
$180.80 |
| D1999 |
|
739 |
473 |
$0.00 |