| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,022 |
3,849 |
$163K |
| D0120 |
Periodic oral evaluation - established patient |
4,668 |
4,452 |
$128K |
| D1351 |
Sealant - per tooth |
1,722 |
900 |
$116K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,538 |
3,378 |
$90K |
| D1110 |
Prophylaxis - adult |
1,550 |
1,474 |
$64K |
| D0274 |
Bitewings - four radiographic images |
2,703 |
2,563 |
$46K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,908 |
1,828 |
$42K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
459 |
338 |
$31K |
| D0220 |
Intraoral - periapical first radiographic image |
4,845 |
4,578 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,145 |
3,854 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
1,097 |
1,048 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
518 |
501 |
$13K |
| D0330 |
Panoramic radiographic image |
433 |
432 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
196 |
154 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
92 |
70 |
$6K |
| D1206 |
Topical application of fluoride varnish |
222 |
222 |
$6K |
| D0272 |
Bitewings - two radiographic images |
386 |
363 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
21 |
13 |
$1K |
| D0270 |
|
31 |
31 |
$173.60 |