| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,604 |
1,359 |
$65K |
| D0120 |
Periodic oral evaluation - established patient |
1,715 |
1,422 |
$47K |
| D1208 |
Topical application of fluoride, excluding varnish |
824 |
710 |
$21K |
| D1206 |
Topical application of fluoride varnish |
747 |
620 |
$19K |
| D0274 |
Bitewings - four radiographic images |
1,107 |
915 |
$18K |
| D1110 |
Prophylaxis - adult |
359 |
300 |
$14K |
| D1351 |
Sealant - per tooth |
225 |
114 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
563 |
461 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
158 |
99 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
1,317 |
1,072 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,214 |
917 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
276 |
221 |
$4K |
| D0272 |
Bitewings - two radiographic images |
274 |
243 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
12 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
16 |
$987.20 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
12 |
12 |
$746.20 |
| D0270 |
|
15 |
14 |
$84.00 |
| D1999 |
|
779 |
663 |
$0.00 |