| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,098 |
2,098 |
$68K |
| D0120 |
Periodic oral evaluation - established patient |
2,419 |
2,419 |
$52K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,346 |
2,346 |
$26K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
208 |
194 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,349 |
1,345 |
$14K |
| D0272 |
Bitewings - two radiographic images |
1,001 |
1,001 |
$13K |
| D1110 |
Prophylaxis - adult |
175 |
175 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,018 |
1,018 |
$6K |
| D1351 |
Sealant - per tooth |
36 |
29 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
27 |
27 |
$1K |
| D1206 |
Topical application of fluoride varnish |
41 |
41 |
$951.50 |
| D7140 |
Extraction, erupted tooth or exposed root |
13 |
13 |
$471.24 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
15 |
$156.80 |
| D1999 |
|
13 |
13 |
$0.00 |