| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
12,128 |
11,963 |
$479K |
| D1206 |
Topical application of fluoride varnish |
14,359 |
14,161 |
$390K |
| D1351 |
Sealant - per tooth |
9,387 |
3,004 |
$294K |
| D1330 |
|
9,396 |
9,208 |
$230K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,003 |
1,117 |
$202K |
| D0274 |
Bitewings - four radiographic images |
2,176 |
2,166 |
$124K |
| D0272 |
Bitewings - two radiographic images |
2,541 |
2,530 |
$93K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,578 |
1,573 |
$89K |
| D1110 |
Prophylaxis - adult |
1,446 |
1,433 |
$86K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
948 |
628 |
$75K |
| D0120 |
Periodic oral evaluation - established patient |
598 |
598 |
$28K |
| D1355 |
|
441 |
111 |
$23K |
| D0145 |
Oral evaluation for a patient under three years of age |
54 |
54 |
$4K |
| D9920 |
|
89 |
84 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
55 |
53 |
$3K |
| D0240 |
|
52 |
28 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
68 |
68 |
$2K |
| D7111 |
|
19 |
14 |
$1K |
| D0191 |
|
2,235 |
2,148 |
$0.00 |
| D1353 |
|
36 |
21 |
$0.00 |