| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,332 |
1,332 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
1,427 |
1,427 |
$39K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,630 |
1,630 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
339 |
183 |
$19K |
| D0272 |
Bitewings - two radiographic images |
1,079 |
1,079 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,133 |
1,133 |
$15K |
| D1110 |
Prophylaxis - adult |
197 |
197 |
$11K |
| D0274 |
Bitewings - four radiographic images |
202 |
202 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
358 |
358 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
112 |
66 |
$5K |
| D0240 |
|
216 |
215 |
$3K |
| D0330 |
Panoramic radiographic image |
39 |
39 |
$1K |
| D1351 |
Sealant - per tooth |
35 |
12 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
15 |
12 |
$912.00 |