| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,626 |
2,579 |
$103K |
| D0120 |
Periodic oral evaluation - established patient |
2,862 |
2,795 |
$76K |
| D4341 |
|
437 |
209 |
$71K |
| D1351 |
Sealant - per tooth |
1,380 |
671 |
$70K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
950 |
624 |
$54K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
482 |
300 |
$33K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,012 |
997 |
$26K |
| D0274 |
Bitewings - four radiographic images |
1,480 |
1,427 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
610 |
416 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
930 |
904 |
$19K |
| D1110 |
Prophylaxis - adult |
681 |
648 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
2,371 |
2,289 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
694 |
656 |
$10K |
| D1206 |
Topical application of fluoride varnish |
371 |
356 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,114 |
1,999 |
$9K |
| D0272 |
Bitewings - two radiographic images |
378 |
373 |
$3K |
| D0330 |
Panoramic radiographic image |
48 |
47 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
17 |
14 |
$625.88 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$62.30 |