| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
651 |
583 |
$26K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
92 |
62 |
$25K |
| D7140 |
Extraction, erupted tooth or exposed root |
601 |
197 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
746 |
666 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
317 |
180 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
640 |
573 |
$16K |
| D1351 |
Sealant - per tooth |
229 |
76 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
422 |
382 |
$8K |
| D0274 |
Bitewings - four radiographic images |
497 |
438 |
$8K |
| D1110 |
Prophylaxis - adult |
250 |
221 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
343 |
312 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
368 |
339 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
1,037 |
925 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
81 |
50 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
863 |
708 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
69 |
45 |
$2K |
| D2950 |
|
19 |
12 |
$2K |
| D9110 |
|
37 |
30 |
$1K |
| D0272 |
Bitewings - two radiographic images |
149 |
133 |
$1K |
| D0270 |
|
129 |
115 |
$681.30 |