| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,141 |
5,939 |
$252K |
| D1351 |
Sealant - per tooth |
2,553 |
1,587 |
$197K |
| D0120 |
Periodic oral evaluation - established patient |
6,654 |
6,432 |
$186K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,930 |
5,745 |
$155K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,119 |
884 |
$78K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,366 |
1,055 |
$64K |
| D0274 |
Bitewings - four radiographic images |
2,495 |
2,413 |
$46K |
| D0220 |
Intraoral - periapical first radiographic image |
7,358 |
7,034 |
$45K |
| D4341 |
|
184 |
122 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,892 |
6,546 |
$29K |
| D1110 |
Prophylaxis - adult |
628 |
613 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,193 |
1,153 |
$28K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
349 |
225 |
$20K |
| D0272 |
Bitewings - two radiographic images |
1,623 |
1,574 |
$16K |
| D0270 |
|
2,053 |
1,996 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
555 |
545 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
176 |
153 |
$10K |
| D2140 |
|
210 |
146 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
19 |
$2K |
| D2332 |
|
12 |
12 |
$2K |
| D2330 |
|
15 |
12 |
$991.42 |
| D1206 |
Topical application of fluoride varnish |
33 |
33 |
$900.90 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$308.00 |