| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
697 |
631 |
$28K |
| D1351 |
Sealant - per tooth |
1,256 |
249 |
$23K |
| D0140 |
Limited oral evaluation - problem focused |
788 |
650 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,559 |
1,132 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
590 |
535 |
$17K |
| D0274 |
Bitewings - four radiographic images |
872 |
710 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,133 |
965 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
167 |
157 |
$9K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
86 |
49 |
$5K |
| D1110 |
Prophylaxis - adult |
311 |
249 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
528 |
461 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
71 |
40 |
$4K |
| D4355 |
|
176 |
117 |
$3K |
| D1206 |
Topical application of fluoride varnish |
89 |
89 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
146 |
119 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
42 |
24 |
$2K |
| D2140 |
|
26 |
15 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
13 |
$1K |
| D0350 |
|
88 |
78 |
$963.50 |
| D7111 |
|
18 |
12 |
$527.00 |
| D0602 |
|
17 |
14 |
$60.00 |
| D0601 |
|
20 |
17 |
$55.00 |