| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,874 |
2,696 |
$117K |
| D1351 |
Sealant - per tooth |
1,615 |
779 |
$104K |
| D0120 |
Periodic oral evaluation - established patient |
3,317 |
3,133 |
$91K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,194 |
857 |
$79K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,480 |
2,313 |
$64K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
951 |
707 |
$45K |
| D4341 |
|
166 |
104 |
$41K |
| D0274 |
Bitewings - four radiographic images |
2,280 |
2,166 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,589 |
1,526 |
$36K |
| D1110 |
Prophylaxis - adult |
775 |
765 |
$36K |
| D0220 |
Intraoral - periapical first radiographic image |
3,907 |
3,641 |
$24K |
| D7140 |
Extraction, erupted tooth or exposed root |
398 |
227 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,013 |
2,683 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
311 |
307 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
470 |
456 |
$8K |
| D9110 |
|
159 |
150 |
$8K |
| D1206 |
Topical application of fluoride varnish |
165 |
156 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
29 |
24 |
$2K |
| D0272 |
Bitewings - two radiographic images |
199 |
186 |
$2K |
| D0270 |
|
194 |
193 |
$1K |
| D4910 |
|
14 |
14 |
$938.00 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
15 |
12 |
$803.60 |
| D1999 |
|
496 |
482 |
$0.00 |