| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,055 |
1,052 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
1,401 |
1,397 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
492 |
237 |
$33K |
| D1110 |
Prophylaxis - adult |
603 |
599 |
$26K |
| D1351 |
Sealant - per tooth |
563 |
138 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,645 |
1,627 |
$20K |
| D0274 |
Bitewings - four radiographic images |
628 |
625 |
$14K |
| D1206 |
Topical application of fluoride varnish |
486 |
484 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
289 |
140 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
923 |
921 |
$12K |
| D0272 |
Bitewings - two radiographic images |
662 |
660 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
106 |
71 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
132 |
132 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
216 |
214 |
$1K |
| D9920 |
|
14 |
13 |
$281.30 |
| D1330 |
|
17 |
17 |
$0.00 |