| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,409 |
1,406 |
$60K |
| D0120 |
Periodic oral evaluation - established patient |
1,761 |
1,758 |
$44K |
| D1351 |
Sealant - per tooth |
823 |
187 |
$27K |
| D1110 |
Prophylaxis - adult |
478 |
478 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,259 |
1,256 |
$17K |
| D1206 |
Topical application of fluoride varnish |
595 |
595 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
219 |
155 |
$14K |
| D0272 |
Bitewings - two radiographic images |
787 |
784 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
997 |
991 |
$8K |
| D0274 |
Bitewings - four radiographic images |
239 |
239 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
109 |
82 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
95 |
55 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
915 |
895 |
$4K |
| D0602 |
|
1,794 |
1,792 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$390.00 |
| D0603 |
|
18 |
18 |
$17.00 |
| D1330 |
|
1,064 |
1,064 |
$0.00 |
| D1310 |
|
1,070 |
1,070 |
$0.00 |