| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,532 |
5,304 |
$225K |
| D0120 |
Periodic oral evaluation - established patient |
6,572 |
6,318 |
$184K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,418 |
1,895 |
$168K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,434 |
5,216 |
$141K |
| D1351 |
Sealant - per tooth |
1,538 |
958 |
$124K |
| D1110 |
Prophylaxis - adult |
1,799 |
1,744 |
$69K |
| D0274 |
Bitewings - four radiographic images |
3,071 |
2,948 |
$55K |
| D0220 |
Intraoral - periapical first radiographic image |
8,594 |
8,234 |
$52K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,159 |
2,085 |
$50K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,100 |
922 |
$45K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,999 |
7,683 |
$33K |
| D0272 |
Bitewings - two radiographic images |
1,873 |
1,761 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
929 |
900 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
130 |
117 |
$13K |
| D4342 |
|
70 |
42 |
$9K |
| D2331 |
|
88 |
77 |
$8K |
| D9110 |
|
111 |
109 |
$6K |
| D4341 |
|
28 |
12 |
$5K |
| D0270 |
|
345 |
322 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
19 |
12 |
$2K |
| D2332 |
|
14 |
13 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
14 |
13 |
$1K |
| D2950 |
|
13 |
13 |
$942.76 |