| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,265 |
1,948 |
$97K |
| D1206 |
Topical application of fluoride varnish |
2,136 |
1,832 |
$80K |
| D0274 |
Bitewings - four radiographic images |
2,891 |
2,512 |
$57K |
| D0220 |
Intraoral - periapical first radiographic image |
5,117 |
4,348 |
$53K |
| D0140 |
Limited oral evaluation - problem focused |
1,905 |
1,577 |
$50K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,359 |
456 |
$48K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,759 |
1,558 |
$44K |
| D0330 |
Panoramic radiographic image |
1,201 |
1,032 |
$37K |
| D1351 |
Sealant - per tooth |
1,906 |
270 |
$37K |
| D0210 |
Intraoral - complete series of radiographic images |
809 |
693 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
1,565 |
1,333 |
$31K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,541 |
3,068 |
$31K |
| D1110 |
Prophylaxis - adult |
1,149 |
1,016 |
$20K |
| D7140 |
Extraction, erupted tooth or exposed root |
135 |
75 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
136 |
57 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
79 |
41 |
$4K |
| D0270 |
|
229 |
200 |
$2K |
| D0999 |
Unspecified diagnostic procedure, by report |
61 |
61 |
$2K |
| D0160 |
|
73 |
65 |
$2K |
| D9999 |
Unspecified adjunctive procedure, by report |
58 |
58 |
$1K |
| D4355 |
|
44 |
17 |
$175.00 |
| D1999 |
|
93 |
85 |
$0.00 |