| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,459 |
6,459 |
$236K |
| D0120 |
Periodic oral evaluation - established patient |
8,788 |
8,788 |
$228K |
| D1351 |
Sealant - per tooth |
3,741 |
1,101 |
$152K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,572 |
1,007 |
$122K |
| D1208 |
Topical application of fluoride, excluding varnish |
8,805 |
8,805 |
$119K |
| D1110 |
Prophylaxis - adult |
2,469 |
2,469 |
$116K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,096 |
1,295 |
$98K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,631 |
4,630 |
$76K |
| D0272 |
Bitewings - two radiographic images |
3,774 |
3,774 |
$59K |
| D7140 |
Extraction, erupted tooth or exposed root |
649 |
422 |
$37K |
| D0330 |
Panoramic radiographic image |
643 |
643 |
$23K |
| D0274 |
Bitewings - four radiographic images |
519 |
519 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
551 |
546 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
86 |
86 |
$2K |
| D1206 |
Topical application of fluoride varnish |
77 |
77 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
15 |
12 |
$2K |
| D1999 |
|
123 |
123 |
$0.00 |