| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
382 |
347 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
462 |
420 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
349 |
315 |
$9K |
| D1351 |
Sealant - per tooth |
56 |
40 |
$6K |
| D1110 |
Prophylaxis - adult |
143 |
132 |
$6K |
| D0274 |
Bitewings - four radiographic images |
317 |
289 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
160 |
140 |
$3K |
| D2140 |
|
44 |
26 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
24 |
19 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
41 |
36 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
335 |
297 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
13 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
221 |
196 |
$995.60 |
| D0272 |
Bitewings - two radiographic images |
109 |
97 |
$968.20 |
| D0140 |
Limited oral evaluation - problem focused |
55 |
47 |
$826.20 |
| D0330 |
Panoramic radiographic image |
18 |
18 |
$318.40 |
| D1999 |
|
384 |
324 |
$0.00 |