| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
7,208 |
7,111 |
$317K |
| D1351 |
Sealant - per tooth |
9,035 |
1,749 |
$314K |
| D1110 |
Prophylaxis - adult |
4,758 |
4,642 |
$276K |
| D1208 |
Topical application of fluoride, excluding varnish |
11,430 |
11,262 |
$264K |
| D0120 |
Periodic oral evaluation - established patient |
8,829 |
8,684 |
$261K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,663 |
3,577 |
$192K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,300 |
858 |
$173K |
| D0220 |
Intraoral - periapical first radiographic image |
12,446 |
12,096 |
$119K |
| D0274 |
Bitewings - four radiographic images |
4,534 |
4,426 |
$98K |
| D7140 |
Extraction, erupted tooth or exposed root |
705 |
398 |
$87K |
| D0230 |
Intraoral - periapical each additional radiographic image |
11,264 |
11,006 |
$80K |
| D0272 |
Bitewings - two radiographic images |
3,295 |
3,252 |
$51K |
| D4341 |
|
565 |
209 |
$49K |
| D0140 |
Limited oral evaluation - problem focused |
937 |
917 |
$43K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
280 |
184 |
$27K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
31 |
26 |
$12K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
12 |
12 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
51 |
38 |
$9K |
| D2750 |
|
16 |
14 |
$8K |
| D2950 |
|
33 |
28 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
60 |
54 |
$2K |
| D1330 |
|
124 |
124 |
$744.00 |