| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
891 |
866 |
$36K |
| D1351 |
Sealant - per tooth |
332 |
224 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
868 |
840 |
$24K |
| D1206 |
Topical application of fluoride varnish |
855 |
829 |
$22K |
| D2740 |
Crown - porcelain/ceramic |
46 |
28 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
493 |
472 |
$12K |
| D0274 |
Bitewings - four radiographic images |
659 |
630 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,659 |
1,229 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,515 |
1,438 |
$9K |
| D1110 |
Prophylaxis - adult |
168 |
164 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
103 |
72 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
259 |
251 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
28 |
25 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
53 |
40 |
$3K |
| D0272 |
Bitewings - two radiographic images |
199 |
194 |
$2K |
| D1354 |
|
18 |
12 |
$697.95 |
| D0330 |
Panoramic radiographic image |
13 |
12 |
$364.00 |
| D0270 |
|
12 |
12 |
$67.20 |