| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,124 |
2,124 |
$68K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
975 |
443 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
1,701 |
1,701 |
$38K |
| D1351 |
Sealant - per tooth |
988 |
319 |
$33K |
| D1206 |
Topical application of fluoride varnish |
986 |
986 |
$27K |
| D0272 |
Bitewings - two radiographic images |
1,156 |
1,156 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,335 |
1,335 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
349 |
213 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,300 |
1,295 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
548 |
548 |
$12K |
| D1110 |
Prophylaxis - adult |
218 |
218 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
127 |
84 |
$8K |
| D0330 |
Panoramic radiographic image |
172 |
172 |
$6K |
| D1354 |
|
138 |
31 |
$5K |
| D0274 |
Bitewings - four radiographic images |
207 |
207 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
38 |
25 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$77.00 |
| D1999 |
|
657 |
636 |
$0.00 |