| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,197 |
5,005 |
$275K |
| D1206 |
Topical application of fluoride varnish |
5,132 |
4,941 |
$178K |
| D0120 |
Periodic oral evaluation - established patient |
3,924 |
3,721 |
$135K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,259 |
993 |
$81K |
| D1351 |
Sealant - per tooth |
1,359 |
585 |
$80K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
910 |
772 |
$37K |
| D0272 |
Bitewings - two radiographic images |
1,616 |
1,557 |
$20K |
| D0274 |
Bitewings - four radiographic images |
866 |
839 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
500 |
491 |
$13K |
| D1354 |
|
212 |
114 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
487 |
475 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
35 |
35 |
$955.50 |
| D0230 |
Intraoral - periapical each additional radiographic image |
139 |
136 |
$933.44 |
| D1110 |
Prophylaxis - adult |
13 |
12 |
$580.56 |
| D0140 |
Limited oral evaluation - problem focused |
29 |
29 |
$516.24 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
13 |
12 |
$428.75 |
| D0270 |
|
14 |
14 |
$78.40 |
| D1330 |
|
525 |
517 |
$0.00 |
| D0601 |
|
1,276 |
1,195 |
$0.00 |
| D0602 |
|
613 |
571 |
$0.00 |
| D0603 |
|
301 |
262 |
$0.00 |