| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
8,275 |
8,257 |
$321K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,699 |
608 |
$223K |
| D1206 |
Topical application of fluoride varnish |
8,589 |
8,570 |
$222K |
| D1351 |
Sealant - per tooth |
5,839 |
1,039 |
$171K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,609 |
3,608 |
$143K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,409 |
505 |
$139K |
| D0191 |
|
3,838 |
3,827 |
$105K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
267 |
167 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
1,343 |
1,339 |
$37K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,683 |
771 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
178 |
99 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
781 |
780 |
$14K |
| D0274 |
Bitewings - four radiographic images |
315 |
315 |
$10K |
| D0272 |
Bitewings - two radiographic images |
224 |
223 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
164 |
164 |
$5K |
| D3110 |
|
44 |
27 |
$2K |
| D1110 |
Prophylaxis - adult |
14 |
14 |
$388.08 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$250.38 |