| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,587 |
6,330 |
$162K |
| D1208 |
Topical application of fluoride, excluding varnish |
7,262 |
6,956 |
$83K |
| D0120 |
Periodic oral evaluation - established patient |
7,113 |
6,979 |
$68K |
| D0230 |
Intraoral - periapical each additional radiographic image |
28,899 |
6,652 |
$65K |
| D1351 |
Sealant - per tooth |
3,143 |
1,153 |
$63K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,678 |
2,320 |
$51K |
| D0220 |
Intraoral - periapical first radiographic image |
7,970 |
7,258 |
$38K |
| D0274 |
Bitewings - four radiographic images |
5,047 |
4,935 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,573 |
1,322 |
$25K |
| D0170 |
|
542 |
528 |
$17K |
| D1310 |
|
8,055 |
7,838 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
970 |
938 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
441 |
434 |
$7K |
| D9999 |
Unspecified adjunctive procedure, by report |
71 |
66 |
$5K |
| D9430 |
|
387 |
373 |
$3K |
| D0603 |
|
2,158 |
2,145 |
$3K |
| D1320 |
|
1,705 |
1,656 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
28 |
26 |
$693.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
15 |
12 |
$491.00 |
| D1352 |
|
102 |
53 |
$222.00 |
| D0270 |
|
86 |
85 |
$175.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$160.00 |
| D0272 |
Bitewings - two radiographic images |
24 |
24 |
$140.00 |
| D1330 |
|
6,288 |
6,159 |
$0.00 |
| D4355 |
|
226 |
221 |
$0.00 |
| D9995 |
|
441 |
415 |
$0.00 |