| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,523 |
2,520 |
$88K |
| D1120 |
Prophylaxis - child |
2,026 |
2,026 |
$86K |
| D1351 |
Sealant - per tooth |
563 |
401 |
$64K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,968 |
1,968 |
$53K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
537 |
475 |
$42K |
| D4341 |
|
132 |
78 |
$22K |
| D0274 |
Bitewings - four radiographic images |
1,037 |
1,036 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
357 |
319 |
$20K |
| D1110 |
Prophylaxis - adult |
406 |
406 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
2,818 |
2,809 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,646 |
2,646 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
439 |
439 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
104 |
99 |
$10K |
| D0270 |
|
967 |
967 |
$5K |
| D0272 |
Bitewings - two radiographic images |
480 |
480 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
55 |
52 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
174 |
173 |
$3K |
| D9110 |
|
15 |
15 |
$825.00 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$508.80 |