| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,093 |
1,093 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
971 |
971 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
222 |
137 |
$23K |
| D1206 |
Topical application of fluoride varnish |
455 |
455 |
$14K |
| D1351 |
Sealant - per tooth |
298 |
99 |
$13K |
| D0272 |
Bitewings - two radiographic images |
645 |
645 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
746 |
746 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
259 |
259 |
$8K |
| D0240 |
|
305 |
191 |
$6K |
| D1110 |
Prophylaxis - adult |
91 |
91 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
264 |
262 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
48 |
32 |
$3K |
| D9990 |
|
105 |
99 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
12 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
46 |
46 |
$452.22 |
| D0230 |
Intraoral - periapical each additional radiographic image |
41 |
41 |
$308.78 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$166.11 |