| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,531 |
2,416 |
$102K |
| D9110 |
|
1,827 |
1,670 |
$98K |
| D1351 |
Sealant - per tooth |
1,313 |
529 |
$97K |
| D0120 |
Periodic oral evaluation - established patient |
3,193 |
3,069 |
$87K |
| D1110 |
Prophylaxis - adult |
1,231 |
1,190 |
$50K |
| D1206 |
Topical application of fluoride varnish |
1,901 |
1,830 |
$49K |
| D0274 |
Bitewings - four radiographic images |
2,297 |
2,211 |
$41K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,367 |
1,292 |
$30K |
| D0220 |
Intraoral - periapical first radiographic image |
5,011 |
4,731 |
$30K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
236 |
126 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,438 |
3,261 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
605 |
588 |
$11K |
| D2332 |
|
68 |
39 |
$10K |
| D2331 |
|
40 |
26 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
52 |
39 |
$4K |
| D0272 |
Bitewings - two radiographic images |
78 |
72 |
$797.42 |