| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,077 |
2,077 |
$88K |
| D1351 |
Sealant - per tooth |
1,437 |
565 |
$77K |
| D0120 |
Periodic oral evaluation - established patient |
2,553 |
2,547 |
$73K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
914 |
567 |
$59K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,884 |
1,884 |
$51K |
| D0274 |
Bitewings - four radiographic images |
1,349 |
1,345 |
$26K |
| D1110 |
Prophylaxis - adult |
496 |
491 |
$23K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
198 |
165 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
294 |
211 |
$18K |
| D4341 |
|
125 |
68 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
370 |
281 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
2,014 |
1,985 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
484 |
483 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,934 |
1,778 |
$10K |
| D0272 |
Bitewings - two radiographic images |
345 |
345 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
161 |
158 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
18 |
13 |
$1K |