| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,240 |
1,142 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
1,565 |
1,450 |
$43K |
| D4341 |
|
280 |
204 |
$41K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,207 |
1,107 |
$31K |
| D1351 |
Sealant - per tooth |
441 |
213 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
368 |
303 |
$22K |
| D0274 |
Bitewings - four radiographic images |
1,093 |
1,000 |
$19K |
| D4342 |
|
169 |
119 |
$15K |
| D0330 |
Panoramic radiographic image |
401 |
361 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
428 |
405 |
$10K |
| D1110 |
Prophylaxis - adult |
201 |
187 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
97 |
90 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
125 |
105 |
$5K |
| D9110 |
|
80 |
71 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
694 |
645 |
$4K |
| D9630 |
|
167 |
165 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
54 |
12 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
463 |
397 |
$3K |
| D0272 |
Bitewings - two radiographic images |
232 |
203 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
23 |
13 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
38 |
30 |
$583.20 |
| D9995 |
|
37 |
29 |
$180.06 |