| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,295 |
1,193 |
$48K |
| D1351 |
Sealant - per tooth |
821 |
363 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
1,441 |
1,303 |
$34K |
| D7140 |
Extraction, erupted tooth or exposed root |
520 |
298 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
892 |
823 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
331 |
211 |
$17K |
| D1110 |
Prophylaxis - adult |
545 |
471 |
$17K |
| D0274 |
Bitewings - four radiographic images |
817 |
726 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
547 |
488 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
228 |
166 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
430 |
381 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
967 |
840 |
$5K |
| D0272 |
Bitewings - two radiographic images |
416 |
383 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
54 |
48 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
53 |
40 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
271 |
228 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
29 |
25 |
$686.30 |