| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,899 |
3,819 |
$162K |
| D0120 |
Periodic oral evaluation - established patient |
4,119 |
3,947 |
$107K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,520 |
4,374 |
$99K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,182 |
1,054 |
$48K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
597 |
301 |
$47K |
| D0274 |
Bitewings - four radiographic images |
1,370 |
1,311 |
$45K |
| D1110 |
Prophylaxis - adult |
1,361 |
1,257 |
$37K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
556 |
265 |
$37K |
| D1206 |
Topical application of fluoride varnish |
1,087 |
1,039 |
$27K |
| D0210 |
Intraoral - complete series of radiographic images |
426 |
406 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
667 |
639 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
889 |
786 |
$10K |
| D1351 |
Sealant - per tooth |
169 |
53 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
370 |
318 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
41 |
17 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
29 |
15 |
$3K |
| D0330 |
Panoramic radiographic image |
32 |
27 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
27 |
12 |
$948.48 |
| D0272 |
Bitewings - two radiographic images |
14 |
13 |
$298.88 |