| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,278 |
3,278 |
$127K |
| D0120 |
Periodic oral evaluation - established patient |
4,027 |
4,027 |
$106K |
| D1206 |
Topical application of fluoride varnish |
3,235 |
3,235 |
$88K |
| D1110 |
Prophylaxis - adult |
906 |
906 |
$47K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
489 |
292 |
$37K |
| D0272 |
Bitewings - two radiographic images |
2,012 |
2,012 |
$31K |
| D1351 |
Sealant - per tooth |
405 |
125 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
768 |
768 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
206 |
116 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
818 |
816 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
570 |
570 |
$8K |
| D0274 |
Bitewings - four radiographic images |
271 |
271 |
$6K |
| D0240 |
|
267 |
267 |
$5K |
| D0330 |
Panoramic radiographic image |
47 |
47 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
23 |
12 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
15 |
$409.50 |