| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,654 |
1,654 |
$69K |
| D0120 |
Periodic oral evaluation - established patient |
2,115 |
2,115 |
$66K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
718 |
458 |
$49K |
| D1110 |
Prophylaxis - adult |
535 |
535 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,712 |
1,712 |
$23K |
| D1351 |
Sealant - per tooth |
538 |
192 |
$20K |
| D0272 |
Bitewings - two radiographic images |
1,218 |
1,218 |
$19K |
| D0274 |
Bitewings - four radiographic images |
615 |
615 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,128 |
1,127 |
$15K |
| D1353 |
|
513 |
194 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
161 |
101 |
$8K |
| D1206 |
Topical application of fluoride varnish |
247 |
247 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
14 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
52 |
52 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
37 |
37 |
$214.35 |
| D1999 |
|
625 |
612 |
$0.00 |
| D1330 |
|
1,894 |
1,894 |
$0.00 |
| D0602 |
|
877 |
877 |
$0.00 |
| D0603 |
|
820 |
819 |
$0.00 |
| D0601 |
|
68 |
68 |
$0.00 |