| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,204 |
3,119 |
$128K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,235 |
3,143 |
$82K |
| D0120 |
Periodic oral evaluation - established patient |
2,978 |
2,884 |
$79K |
| D1351 |
Sealant - per tooth |
1,338 |
565 |
$71K |
| D4342 |
|
497 |
221 |
$64K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
643 |
434 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,753 |
1,681 |
$36K |
| D0274 |
Bitewings - four radiographic images |
2,066 |
1,982 |
$30K |
| D0210 |
Intraoral - complete series of radiographic images |
793 |
759 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
3,658 |
3,519 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,738 |
3,326 |
$18K |
| D4341 |
|
37 |
12 |
$6K |
| D1110 |
Prophylaxis - adult |
179 |
169 |
$5K |
| D0272 |
Bitewings - two radiographic images |
626 |
610 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
58 |
50 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
227 |
219 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
20 |
13 |
$1K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
16 |
14 |
$914.85 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
13 |
$555.30 |
| D0330 |
Panoramic radiographic image |
17 |
17 |
$229.80 |