| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
989 |
883 |
$39K |
| D1206 |
Topical application of fluoride varnish |
926 |
826 |
$29K |
| D0274 |
Bitewings - four radiographic images |
1,144 |
1,053 |
$25K |
| D0140 |
Limited oral evaluation - problem focused |
628 |
514 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,309 |
1,167 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
521 |
469 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,187 |
1,440 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
579 |
507 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
188 |
122 |
$7K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
193 |
49 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
111 |
41 |
$4K |
| D1351 |
Sealant - per tooth |
64 |
14 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
37 |
14 |
$1K |
| D0602 |
|
194 |
171 |
$809.00 |
| D1999 |
|
26 |
26 |
$390.00 |
| D0999 |
Unspecified diagnostic procedure, by report |
21 |
15 |
$390.00 |
| D1110 |
Prophylaxis - adult |
17 |
15 |
$345.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
25 |
25 |
$250.00 |
| D0601 |
|
12 |
12 |
$60.00 |