| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,004 |
1,003 |
$42K |
| D7140 |
Extraction, erupted tooth or exposed root |
552 |
279 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
1,241 |
1,238 |
$35K |
| D1206 |
Topical application of fluoride varnish |
1,006 |
1,003 |
$27K |
| D1110 |
Prophylaxis - adult |
505 |
504 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
333 |
284 |
$22K |
| D0274 |
Bitewings - four radiographic images |
1,090 |
1,085 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
735 |
732 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,867 |
1,845 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
110 |
102 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
542 |
534 |
$10K |
| D4342 |
|
91 |
44 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
206 |
164 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,570 |
1,540 |
$9K |
| D0330 |
Panoramic radiographic image |
132 |
132 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
106 |
106 |
$2K |
| D2335 |
|
24 |
14 |
$2K |
| D1351 |
Sealant - per tooth |
28 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
96 |
96 |
$1K |