| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
710 |
656 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
718 |
662 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
294 |
224 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
635 |
592 |
$16K |
| D9110 |
|
176 |
141 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
112 |
83 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
100 |
62 |
$7K |
| D0274 |
Bitewings - four radiographic images |
453 |
404 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
1,024 |
940 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
823 |
753 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
240 |
222 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
251 |
230 |
$4K |
| D1110 |
Prophylaxis - adult |
65 |
64 |
$2K |
| D1351 |
Sealant - per tooth |
17 |
14 |
$2K |
| D0272 |
Bitewings - two radiographic images |
76 |
73 |
$705.00 |