| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,629 |
2,623 |
$112K |
| D0120 |
Periodic oral evaluation - established patient |
3,383 |
3,375 |
$97K |
| D1351 |
Sealant - per tooth |
1,272 |
580 |
$90K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
829 |
586 |
$86K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,224 |
824 |
$85K |
| D4341 |
|
407 |
176 |
$72K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,587 |
2,581 |
$70K |
| D0274 |
Bitewings - four radiographic images |
3,308 |
3,297 |
$52K |
| D1110 |
Prophylaxis - adult |
953 |
948 |
$45K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,492 |
1,486 |
$38K |
| D4342 |
|
297 |
139 |
$34K |
| D0220 |
Intraoral - periapical first radiographic image |
4,610 |
4,575 |
$30K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
311 |
233 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,036 |
4,261 |
$27K |
| D2332 |
|
161 |
108 |
$18K |
| D0603 |
|
130 |
130 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
333 |
276 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
231 |
168 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
525 |
517 |
$10K |
| D0602 |
|
74 |
74 |
$10K |
| D4910 |
|
99 |
99 |
$6K |
| D0601 |
|
52 |
52 |
$6K |
| D2394 |
|
59 |
56 |
$5K |
| D0330 |
Panoramic radiographic image |
203 |
203 |
$4K |
| D2335 |
|
37 |
28 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
157 |
157 |
$4K |
| D0272 |
Bitewings - two radiographic images |
383 |
383 |
$4K |
| D0270 |
|
111 |
110 |
$614.89 |