| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,548 |
1,548 |
$52K |
| D0120 |
Periodic oral evaluation - established patient |
1,661 |
1,661 |
$39K |
| D1351 |
Sealant - per tooth |
1,057 |
347 |
$39K |
| D1206 |
Topical application of fluoride varnish |
621 |
621 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,115 |
1,115 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
264 |
159 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
168 |
87 |
$9K |
| D0330 |
Panoramic radiographic image |
236 |
236 |
$7K |
| D0274 |
Bitewings - four radiographic images |
264 |
264 |
$7K |
| D1110 |
Prophylaxis - adult |
155 |
155 |
$7K |
| D0272 |
Bitewings - two radiographic images |
406 |
406 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
74 |
53 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
163 |
161 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
24 |
24 |
$570.00 |