| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,009 |
3,998 |
$165K |
| D0120 |
Periodic oral evaluation - established patient |
5,469 |
5,458 |
$135K |
| D0274 |
Bitewings - four radiographic images |
4,856 |
4,853 |
$116K |
| D1351 |
Sealant - per tooth |
2,997 |
976 |
$108K |
| D2394 |
|
1,011 |
591 |
$99K |
| D1110 |
Prophylaxis - adult |
1,943 |
1,942 |
$87K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,442 |
4,437 |
$60K |
| D0220 |
Intraoral - periapical first radiographic image |
5,832 |
5,752 |
$52K |
| D1206 |
Topical application of fluoride varnish |
1,515 |
1,513 |
$37K |
| D7140 |
Extraction, erupted tooth or exposed root |
732 |
454 |
$36K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,120 |
4,907 |
$29K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
213 |
145 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
213 |
213 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
12 |
$1K |
| D1320 |
|
98 |
98 |
$644.50 |
| D9110 |
|
15 |
14 |
$360.72 |