| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,986 |
2,946 |
$99K |
| D0120 |
Periodic oral evaluation - established patient |
3,267 |
3,227 |
$89K |
| D1351 |
Sealant - per tooth |
1,832 |
671 |
$60K |
| D1206 |
Topical application of fluoride varnish |
2,380 |
2,344 |
$54K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
538 |
289 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
239 |
143 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
662 |
662 |
$7K |
| D0272 |
Bitewings - two radiographic images |
437 |
428 |
$4K |
| D0274 |
Bitewings - four radiographic images |
166 |
166 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
337 |
325 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
35 |
25 |
$1K |
| D1110 |
Prophylaxis - adult |
39 |
39 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
237 |
225 |
$965.40 |
| D0603 |
|
245 |
242 |
$930.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
44 |
44 |
$778.80 |
| D0140 |
Limited oral evaluation - problem focused |
17 |
15 |
$391.00 |
| D0602 |
|
432 |
424 |
$0.00 |
| D0601 |
|
1,763 |
1,740 |
$0.00 |