| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
10,703 |
10,116 |
$435K |
| D1351 |
Sealant - per tooth |
4,165 |
2,451 |
$337K |
| D0120 |
Periodic oral evaluation - established patient |
10,724 |
10,201 |
$298K |
| D1208 |
Topical application of fluoride, excluding varnish |
9,605 |
9,097 |
$248K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,485 |
1,226 |
$114K |
| D0274 |
Bitewings - four radiographic images |
4,837 |
4,604 |
$86K |
| D1110 |
Prophylaxis - adult |
1,359 |
1,304 |
$58K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,070 |
1,919 |
$45K |
| D0220 |
Intraoral - periapical first radiographic image |
6,975 |
6,579 |
$41K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
705 |
590 |
$33K |
| D0140 |
Limited oral evaluation - problem focused |
1,746 |
1,593 |
$30K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,201 |
5,854 |
$26K |
| D0272 |
Bitewings - two radiographic images |
556 |
512 |
$5K |
| D9630 |
|
191 |
178 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
44 |
42 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
27 |
27 |
$2K |
| D0330 |
Panoramic radiographic image |
64 |
64 |
$2K |
| D1206 |
Topical application of fluoride varnish |
66 |
66 |
$2K |