| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
987 |
987 |
$42K |
| D1351 |
Sealant - per tooth |
555 |
289 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,115 |
1,115 |
$32K |
| D1208 |
Topical application of fluoride, excluding varnish |
990 |
990 |
$26K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
333 |
273 |
$21K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
235 |
168 |
$21K |
| D0274 |
Bitewings - four radiographic images |
794 |
794 |
$15K |
| D4341 |
|
84 |
50 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
491 |
491 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,772 |
1,740 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
576 |
553 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,346 |
1,336 |
$9K |
| D1110 |
Prophylaxis - adult |
156 |
156 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
155 |
125 |
$7K |
| D9110 |
|
120 |
115 |
$7K |
| D0272 |
Bitewings - two radiographic images |
89 |
89 |
$987.01 |
| D0210 |
Intraoral - complete series of radiographic images |
57 |
57 |
$769.62 |
| D0270 |
|
59 |
59 |
$330.40 |