| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
620 |
600 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
527 |
511 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
451 |
434 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
501 |
479 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
239 |
228 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
154 |
89 |
$6K |
| D1351 |
Sealant - per tooth |
147 |
61 |
$5K |
| D4341 |
|
35 |
17 |
$5K |
| D1110 |
Prophylaxis - adult |
124 |
117 |
$4K |
| D1206 |
Topical application of fluoride varnish |
160 |
157 |
$4K |
| D0274 |
Bitewings - four radiographic images |
197 |
191 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
42 |
32 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
422 |
405 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
132 |
125 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
42 |
26 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
301 |
292 |
$1K |
| D0272 |
Bitewings - two radiographic images |
27 |
27 |
$216.20 |
| D0602 |
|
46 |
44 |
$0.00 |
| D0601 |
|
58 |
58 |
$0.00 |