| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
630 |
609 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
658 |
638 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
626 |
605 |
$16K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
216 |
150 |
$13K |
| D1351 |
Sealant - per tooth |
266 |
126 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
101 |
71 |
$5K |
| D0274 |
Bitewings - four radiographic images |
256 |
249 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
48 |
36 |
$3K |
| D1110 |
Prophylaxis - adult |
110 |
106 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
126 |
122 |
$3K |
| D2140 |
|
76 |
49 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
113 |
111 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
44 |
30 |
$2K |
| D0272 |
Bitewings - two radiographic images |
152 |
145 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
240 |
230 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
15 |
$1K |
| D2160 |
|
16 |
13 |
$996.75 |
| D0230 |
Intraoral - periapical each additional radiographic image |
172 |
162 |
$877.80 |