| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
579 |
579 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
715 |
715 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
292 |
162 |
$19K |
| D1351 |
Sealant - per tooth |
280 |
114 |
$10K |
| D1110 |
Prophylaxis - adult |
181 |
181 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
511 |
511 |
$7K |
| D0272 |
Bitewings - two radiographic images |
430 |
430 |
$7K |
| D1353 |
|
333 |
115 |
$6K |
| D0274 |
Bitewings - four radiographic images |
215 |
215 |
$6K |
| D1206 |
Topical application of fluoride varnish |
203 |
203 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
363 |
357 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
82 |
53 |
$5K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
34 |
21 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
68 |
47 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
25 |
25 |
$677.75 |
| D0230 |
Intraoral - periapical each additional radiographic image |
32 |
32 |
$307.85 |
| D0603 |
|
356 |
356 |
$21.25 |
| D1330 |
|
514 |
514 |
$13.00 |
| D0602 |
|
40 |
40 |
$0.00 |
| D0601 |
|
90 |
90 |
$0.00 |