| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,029 |
982 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
992 |
947 |
$27K |
| D1351 |
Sealant - per tooth |
485 |
223 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
941 |
895 |
$23K |
| D0274 |
Bitewings - four radiographic images |
529 |
502 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
114 |
69 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
356 |
341 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
1,207 |
1,139 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,159 |
1,058 |
$5K |
| D4341 |
|
26 |
12 |
$4K |
| D0272 |
Bitewings - two radiographic images |
285 |
268 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
46 |
38 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
29 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
57 |
39 |
$2K |
| D1110 |
Prophylaxis - adult |
45 |
39 |
$1K |
| D4910 |
|
14 |
14 |
$938.00 |
| D0140 |
Limited oral evaluation - problem focused |
42 |
40 |
$664.20 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$338.00 |