| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
835 |
739 |
$34K |
| D1351 |
Sealant - per tooth |
406 |
176 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
759 |
670 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
342 |
251 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
768 |
679 |
$20K |
| D4341 |
|
97 |
60 |
$15K |
| D0274 |
Bitewings - four radiographic images |
849 |
743 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
633 |
556 |
$14K |
| D1110 |
Prophylaxis - adult |
283 |
263 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
126 |
98 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
178 |
104 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
1,372 |
1,183 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
202 |
154 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,207 |
1,023 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
271 |
239 |
$5K |
| D0272 |
Bitewings - two radiographic images |
175 |
158 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
18 |
13 |
$105.50 |
| D0270 |
|
14 |
14 |
$78.40 |
| D1999 |
|
382 |
369 |
$0.00 |