| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,816 |
3,630 |
$156K |
| D0120 |
Periodic oral evaluation - established patient |
5,623 |
5,376 |
$154K |
| D1110 |
Prophylaxis - adult |
2,510 |
2,404 |
$106K |
| D1351 |
Sealant - per tooth |
1,402 |
739 |
$98K |
| D0210 |
Intraoral - complete series of radiographic images |
2,960 |
2,801 |
$91K |
| D2750 |
|
304 |
258 |
$87K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,083 |
847 |
$80K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
746 |
473 |
$76K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,550 |
2,414 |
$66K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,300 |
2,185 |
$51K |
| D0140 |
Limited oral evaluation - problem focused |
2,899 |
2,548 |
$49K |
| D0274 |
Bitewings - four radiographic images |
2,647 |
2,535 |
$47K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
473 |
376 |
$41K |
| D2950 |
|
565 |
485 |
$39K |
| D4341 |
|
210 |
117 |
$38K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
282 |
183 |
$14K |
| D2332 |
|
127 |
92 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,821 |
1,720 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
329 |
328 |
$1K |
| D4910 |
|
12 |
12 |
$804.00 |
| D0272 |
Bitewings - two radiographic images |
54 |
54 |
$598.86 |