| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
629 |
525 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
780 |
658 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
534 |
443 |
$13K |
| D9110 |
|
239 |
207 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
274 |
221 |
$11K |
| D1351 |
Sealant - per tooth |
105 |
78 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
995 |
865 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
101 |
87 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
815 |
698 |
$3K |
| D0272 |
Bitewings - two radiographic images |
370 |
294 |
$3K |
| D0330 |
Panoramic radiographic image |
141 |
120 |
$3K |
| D4342 |
|
18 |
13 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
97 |
83 |
$2K |
| D1206 |
Topical application of fluoride varnish |
73 |
61 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
120 |
118 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
36 |
29 |
$2K |
| D1110 |
Prophylaxis - adult |
38 |
29 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
18 |
12 |
$1K |
| D0270 |
|
205 |
185 |
$1K |
| D2140 |
|
20 |
12 |
$925.50 |
| D0274 |
Bitewings - four radiographic images |
26 |
26 |
$388.70 |