| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
7,353 |
7,270 |
$321K |
| D1208 |
Topical application of fluoride, excluding varnish |
11,335 |
11,208 |
$262K |
| D0120 |
Periodic oral evaluation - established patient |
8,661 |
8,558 |
$261K |
| D1110 |
Prophylaxis - adult |
4,039 |
3,995 |
$257K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,795 |
1,070 |
$236K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,005 |
1,078 |
$206K |
| D1351 |
Sealant - per tooth |
5,275 |
1,020 |
$176K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,128 |
3,097 |
$171K |
| D0220 |
Intraoral - periapical first radiographic image |
9,646 |
9,470 |
$105K |
| D7140 |
Extraction, erupted tooth or exposed root |
667 |
413 |
$85K |
| D0274 |
Bitewings - four radiographic images |
3,279 |
3,241 |
$82K |
| D0330 |
Panoramic radiographic image |
1,533 |
1,518 |
$72K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,713 |
8,553 |
$66K |
| D0272 |
Bitewings - two radiographic images |
3,304 |
3,262 |
$56K |
| D0140 |
Limited oral evaluation - problem focused |
1,060 |
1,034 |
$49K |
| D4341 |
|
320 |
115 |
$27K |
| D2750 |
|
15 |
12 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
55 |
32 |
$6K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
13 |
12 |
$5K |
| D1330 |
|
271 |
260 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
26 |
26 |
$1K |
| D4910 |
|
14 |
14 |
$824.36 |
| D0270 |
|
14 |
14 |
$126.00 |