| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
900 |
807 |
$18K |
| D1351 |
Sealant - per tooth |
93 |
56 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
228 |
144 |
$9K |
| D1120 |
Prophylaxis - child |
264 |
239 |
$9K |
| D1110 |
Prophylaxis - adult |
248 |
237 |
$8K |
| D4342 |
|
44 |
35 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
279 |
253 |
$6K |
| D1206 |
Topical application of fluoride varnish |
217 |
200 |
$5K |
| D0330 |
Panoramic radiographic image |
344 |
305 |
$4K |
| D0274 |
Bitewings - four radiographic images |
394 |
351 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
52 |
47 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
29 |
24 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
40 |
36 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
508 |
442 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
463 |
405 |
$896.04 |
| D0140 |
Limited oral evaluation - problem focused |
26 |
24 |
$407.64 |
| D0272 |
Bitewings - two radiographic images |
54 |
46 |
$253.70 |