| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,632 |
3,507 |
$151K |
| D1351 |
Sealant - per tooth |
3,080 |
995 |
$138K |
| D0120 |
Periodic oral evaluation - established patient |
4,262 |
4,133 |
$120K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,597 |
3,474 |
$95K |
| D4341 |
|
398 |
138 |
$62K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
658 |
373 |
$59K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
905 |
569 |
$54K |
| D0274 |
Bitewings - four radiographic images |
3,153 |
3,062 |
$48K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,268 |
1,217 |
$31K |
| D0220 |
Intraoral - periapical first radiographic image |
4,766 |
4,596 |
$29K |
| D1110 |
Prophylaxis - adult |
622 |
612 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,547 |
4,325 |
$26K |
| D2332 |
|
255 |
118 |
$26K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
246 |
177 |
$19K |
| D4342 |
|
122 |
42 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
303 |
294 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
83 |
63 |
$5K |
| D0272 |
Bitewings - two radiographic images |
658 |
632 |
$5K |
| D0330 |
Panoramic radiographic image |
169 |
168 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
65 |
49 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
116 |
102 |
$2K |
| D4910 |
|
16 |
16 |
$1K |
| D0270 |
|
12 |
12 |
$67.20 |