| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,233 |
5,939 |
$316K |
| D1206 |
Topical application of fluoride varnish |
6,312 |
6,017 |
$209K |
| D1351 |
Sealant - per tooth |
1,848 |
887 |
$107K |
| D0120 |
Periodic oral evaluation - established patient |
3,142 |
2,975 |
$107K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,375 |
1,004 |
$92K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
441 |
366 |
$18K |
| D0272 |
Bitewings - two radiographic images |
1,421 |
1,351 |
$17K |
| D0274 |
Bitewings - four radiographic images |
742 |
720 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
448 |
423 |
$12K |
| D1354 |
|
111 |
83 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
58 |
49 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
342 |
325 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
16 |
13 |
$704.16 |
| DMISS |
|
40 |
35 |
$0.00 |
| START |
Start eoc doc med rec |
13 |
13 |
$0.00 |
| D0601 |
|
1,525 |
1,395 |
$0.00 |
| D0603 |
|
239 |
202 |
$0.00 |
| D0602 |
|
424 |
385 |
$0.00 |
| D1330 |
|
972 |
917 |
$0.00 |
| DC0MP |
|
12 |
12 |
$0.00 |