| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
780 |
734 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
1,080 |
995 |
$29K |
| D1110 |
Prophylaxis - adult |
607 |
572 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
356 |
281 |
$23K |
| D7140 |
Extraction, erupted tooth or exposed root |
386 |
278 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
716 |
679 |
$17K |
| D0274 |
Bitewings - four radiographic images |
771 |
715 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
241 |
198 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
524 |
493 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
313 |
294 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
1,278 |
1,190 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,136 |
1,050 |
$6K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
15 |
15 |
$4K |
| D2331 |
|
43 |
39 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
188 |
177 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
33 |
30 |
$2K |
| D0272 |
Bitewings - two radiographic images |
236 |
215 |
$2K |
| D1351 |
Sealant - per tooth |
22 |
14 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
30 |
27 |
$2K |
| D2330 |
|
12 |
12 |
$657.40 |
| D1999 |
|
631 |
461 |
$0.00 |