| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,197 |
1,073 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
1,167 |
1,029 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
417 |
290 |
$29K |
| D1206 |
Topical application of fluoride varnish |
1,143 |
1,025 |
$27K |
| D0274 |
Bitewings - four radiographic images |
784 |
712 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
447 |
412 |
$9K |
| D1110 |
Prophylaxis - adult |
217 |
210 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,641 |
1,449 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
184 |
135 |
$7K |
| D1351 |
Sealant - per tooth |
101 |
54 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,481 |
1,311 |
$5K |
| D0272 |
Bitewings - two radiographic images |
528 |
473 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
192 |
176 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
52 |
44 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
16 |
14 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
22 |
20 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
22 |
16 |
$390.00 |
| D0270 |
|
70 |
64 |
$386.40 |
| D1999 |
|
101 |
80 |
$0.00 |