| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,318 |
3,191 |
$60K |
| D1351 |
Sealant - per tooth |
3,557 |
1,119 |
$58K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
928 |
549 |
$53K |
| D0120 |
Periodic oral evaluation - established patient |
2,528 |
2,453 |
$53K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,078 |
618 |
$47K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,408 |
1,347 |
$46K |
| D1206 |
Topical application of fluoride varnish |
3,802 |
3,666 |
$44K |
| D0274 |
Bitewings - four radiographic images |
1,784 |
1,731 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,477 |
1,630 |
$22K |
| D0272 |
Bitewings - two radiographic images |
1,400 |
1,336 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,948 |
1,864 |
$16K |
| D1110 |
Prophylaxis - adult |
515 |
508 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
294 |
144 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
169 |
145 |
$2K |