| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
476 |
466 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
537 |
526 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
462 |
452 |
$11K |
| D0274 |
Bitewings - four radiographic images |
339 |
332 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
43 |
30 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
62 |
58 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
80 |
72 |
$3K |
| D1351 |
Sealant - per tooth |
29 |
27 |
$3K |
| D4342 |
|
18 |
12 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
101 |
101 |
$2K |
| D0330 |
Panoramic radiographic image |
81 |
80 |
$2K |
| D1110 |
Prophylaxis - adult |
45 |
44 |
$2K |
| D0272 |
Bitewings - two radiographic images |
116 |
113 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
156 |
153 |
$840.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
15 |
$821.52 |
| D0230 |
Intraoral - periapical each additional radiographic image |
119 |
118 |
$809.40 |
| D9110 |
|
14 |
13 |
$660.00 |
| D1999 |
|
185 |
158 |
$0.00 |