| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,394 |
1,394 |
$59K |
| D0120 |
Periodic oral evaluation - established patient |
1,707 |
1,707 |
$49K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,333 |
1,333 |
$36K |
| D4341 |
|
206 |
141 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
423 |
345 |
$32K |
| D1351 |
Sealant - per tooth |
315 |
228 |
$28K |
| D0274 |
Bitewings - four radiographic images |
1,255 |
1,254 |
$24K |
| D1110 |
Prophylaxis - adult |
439 |
439 |
$21K |
| D4342 |
|
179 |
120 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
639 |
638 |
$16K |
| D9110 |
|
171 |
166 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
160 |
121 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
99 |
93 |
$9K |
| D0330 |
Panoramic radiographic image |
300 |
299 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
1,009 |
1,003 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
772 |
763 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
122 |
111 |
$5K |
| D0272 |
Bitewings - two radiographic images |
352 |
352 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
29 |
19 |
$3K |
| D2950 |
|
30 |
28 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
88 |
87 |
$2K |
| D2335 |
|
13 |
12 |
$1K |
| D9630 |
|
33 |
33 |
$775.50 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$108.68 |
| D1999 |
|
154 |
149 |
$0.00 |