| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,721 |
2,706 |
$57K |
| D1206 |
Topical application of fluoride varnish |
2,791 |
2,772 |
$53K |
| D1120 |
Prophylaxis - child |
1,851 |
1,841 |
$49K |
| D1351 |
Sealant - per tooth |
1,711 |
323 |
$45K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
715 |
446 |
$42K |
| D1110 |
Prophylaxis - adult |
923 |
917 |
$33K |
| D0274 |
Bitewings - four radiographic images |
718 |
715 |
$21K |
| D0272 |
Bitewings - two radiographic images |
1,105 |
1,094 |
$19K |
| D7140 |
Extraction, erupted tooth or exposed root |
359 |
207 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
341 |
238 |
$16K |
| D0330 |
Panoramic radiographic image |
234 |
234 |
$9K |
| D0603 |
|
858 |
857 |
$8K |
| D1330 |
|
1,183 |
1,180 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
37 |
24 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
148 |
147 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
295 |
294 |
$2K |
| D0602 |
|
176 |
175 |
$2K |
| D0240 |
|
88 |
75 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
39 |
39 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
15 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
100 |
77 |
$773.83 |
| D1310 |
|
16 |
16 |
$160.00 |