| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,402 |
2,251 |
$90K |
| D1351 |
Sealant - per tooth |
2,151 |
501 |
$80K |
| D1206 |
Topical application of fluoride varnish |
2,390 |
2,239 |
$57K |
| D0120 |
Periodic oral evaluation - established patient |
2,180 |
1,997 |
$56K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,200 |
521 |
$56K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,032 |
1,927 |
$41K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
676 |
387 |
$40K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
725 |
502 |
$35K |
| D0274 |
Bitewings - four radiographic images |
1,941 |
1,804 |
$30K |
| D1110 |
Prophylaxis - adult |
738 |
642 |
$28K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
369 |
264 |
$20K |
| D0330 |
Panoramic radiographic image |
852 |
799 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
3,059 |
2,864 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,998 |
2,683 |
$11K |
| D2332 |
|
132 |
83 |
$9K |
| D0272 |
Bitewings - two radiographic images |
790 |
748 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
179 |
133 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
97 |
95 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
111 |
110 |
$850.30 |