| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,782 |
2,781 |
$84K |
| D1354 |
|
4,554 |
930 |
$81K |
| D0120 |
Periodic oral evaluation - established patient |
3,265 |
3,265 |
$66K |
| D0274 |
Bitewings - four radiographic images |
2,662 |
2,661 |
$50K |
| D1351 |
Sealant - per tooth |
936 |
221 |
$28K |
| D1206 |
Topical application of fluoride varnish |
1,178 |
1,178 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
2,248 |
2,232 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,143 |
2,143 |
$21K |
| D1110 |
Prophylaxis - adult |
512 |
512 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,662 |
2,647 |
$13K |
| D9990 |
|
587 |
573 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
126 |
126 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
74 |
40 |
$4K |
| D0240 |
|
239 |
239 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
202 |
177 |
$2K |
| D9920 |
|
93 |
84 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
46 |
26 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
12 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
55 |
55 |
$1K |
| D0272 |
Bitewings - two radiographic images |
60 |
60 |
$714.00 |