| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,832 |
2,832 |
$125K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,346 |
1,174 |
$94K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,096 |
1,038 |
$94K |
| D0120 |
Periodic oral evaluation - established patient |
4,229 |
4,229 |
$94K |
| D1120 |
Prophylaxis - child |
2,063 |
2,063 |
$68K |
| D0274 |
Bitewings - four radiographic images |
2,841 |
2,841 |
$63K |
| D0220 |
Intraoral - periapical first radiographic image |
4,936 |
4,854 |
$53K |
| D2160 |
|
423 |
397 |
$39K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,744 |
2,744 |
$30K |
| D2140 |
|
514 |
488 |
$28K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
297 |
282 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
427 |
363 |
$19K |
| D0272 |
Bitewings - two radiographic images |
1,444 |
1,444 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
589 |
589 |
$13K |
| D1206 |
Topical application of fluoride varnish |
507 |
507 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,232 |
1,232 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
46 |
44 |
$2K |
| D1351 |
Sealant - per tooth |
12 |
12 |
$868.32 |
| D9110 |
|
33 |
32 |
$715.77 |
| D0145 |
Oral evaluation for a patient under three years of age |
20 |
20 |
$490.00 |