| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,105 |
2,105 |
$90K |
| D0120 |
Periodic oral evaluation - established patient |
2,393 |
2,393 |
$69K |
| D1351 |
Sealant - per tooth |
811 |
572 |
$57K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,076 |
2,076 |
$56K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
949 |
747 |
$44K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
565 |
467 |
$37K |
| D1110 |
Prophylaxis - adult |
757 |
757 |
$36K |
| D0274 |
Bitewings - four radiographic images |
1,368 |
1,368 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
845 |
845 |
$22K |
| D7140 |
Extraction, erupted tooth or exposed root |
194 |
157 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,594 |
1,557 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
666 |
664 |
$5K |
| D0272 |
Bitewings - two radiographic images |
456 |
456 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
232 |
226 |
$4K |
| D2330 |
|
17 |
13 |
$991.42 |