| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,365 |
1,356 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
1,417 |
1,399 |
$39K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,348 |
1,340 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
563 |
386 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
419 |
286 |
$14K |
| D1110 |
Prophylaxis - adult |
316 |
301 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
403 |
393 |
$8K |
| D0274 |
Bitewings - four radiographic images |
448 |
436 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,155 |
1,124 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
1,231 |
1,204 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
211 |
205 |
$5K |
| D4341 |
|
38 |
12 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
199 |
192 |
$3K |
| D0272 |
Bitewings - two radiographic images |
280 |
277 |
$3K |
| D1351 |
Sealant - per tooth |
39 |
18 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
36 |
25 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
13 |
$870.75 |