| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,536 |
2,447 |
$99K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,454 |
850 |
$90K |
| D0120 |
Periodic oral evaluation - established patient |
2,855 |
2,737 |
$76K |
| D1206 |
Topical application of fluoride varnish |
1,835 |
1,756 |
$45K |
| D1351 |
Sealant - per tooth |
568 |
282 |
$30K |
| D0274 |
Bitewings - four radiographic images |
1,448 |
1,356 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
545 |
347 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
728 |
718 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
2,375 |
2,226 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
251 |
188 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
545 |
516 |
$11K |
| D4342 |
|
105 |
55 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,124 |
1,960 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
498 |
466 |
$8K |
| D1110 |
Prophylaxis - adult |
216 |
194 |
$6K |
| D4341 |
|
23 |
13 |
$4K |
| D0272 |
Bitewings - two radiographic images |
417 |
400 |
$4K |
| D4355 |
|
34 |
34 |
$1K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
20 |
12 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
14 |
$754.65 |