| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
757 |
757 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
392 |
255 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
991 |
991 |
$25K |
| D1110 |
Prophylaxis - adult |
520 |
520 |
$25K |
| D1351 |
Sealant - per tooth |
454 |
140 |
$24K |
| D7140 |
Extraction, erupted tooth or exposed root |
330 |
173 |
$20K |
| D0330 |
Panoramic radiographic image |
813 |
813 |
$20K |
| D1206 |
Topical application of fluoride varnish |
657 |
657 |
$18K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
205 |
144 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
579 |
579 |
$17K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
165 |
136 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
295 |
198 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,573 |
1,568 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,446 |
1,444 |
$7K |
| D0274 |
Bitewings - four radiographic images |
343 |
343 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
334 |
332 |
$6K |
| D4341 |
|
41 |
14 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
170 |
169 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
88 |
88 |
$2K |
| D0272 |
Bitewings - two radiographic images |
154 |
154 |
$2K |
| D2335 |
|
16 |
14 |
$2K |
| D2330 |
|
19 |
17 |
$991.42 |