| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,392 |
5,351 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,497 |
602 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,181 |
6,135 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
5,377 |
5,333 |
$3K |
| D0272 |
Bitewings - two radiographic images |
4,305 |
4,266 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,134 |
1,128 |
$2K |
| D1351 |
Sealant - per tooth |
1,948 |
543 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
335 |
333 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
476 |
308 |
$2K |
| D1354 |
|
5,147 |
1,115 |
$2K |
| D1206 |
Topical application of fluoride varnish |
3,065 |
2,993 |
$1K |
| D1110 |
Prophylaxis - adult |
1,151 |
1,143 |
$857.78 |
| D0220 |
Intraoral - periapical first radiographic image |
1,071 |
1,043 |
$649.61 |
| D0274 |
Bitewings - four radiographic images |
1,156 |
1,147 |
$619.86 |
| D0230 |
Intraoral - periapical each additional radiographic image |
632 |
612 |
$423.45 |
| D1999 |
|
55 |
50 |
$0.00 |
| D0602 |
|
153 |
151 |
$0.00 |
| D0603 |
|
29 |
29 |
$0.00 |
| D0601 |
|
14 |
14 |
$0.00 |