| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,607 |
2,038 |
$134K |
| D1206 |
Topical application of fluoride varnish |
2,509 |
1,962 |
$89K |
| D0120 |
Periodic oral evaluation - established patient |
2,072 |
1,651 |
$82K |
| D1110 |
Prophylaxis - adult |
742 |
539 |
$30K |
| D1351 |
Sealant - per tooth |
199 |
139 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
316 |
208 |
$23K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
145 |
67 |
$21K |
| D0330 |
Panoramic radiographic image |
692 |
508 |
$20K |
| D0274 |
Bitewings - four radiographic images |
793 |
630 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
308 |
224 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
672 |
400 |
$14K |
| D2940 |
|
198 |
137 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
293 |
202 |
$8K |
| D0272 |
Bitewings - two radiographic images |
510 |
393 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
56 |
25 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
212 |
159 |
$2K |
| 0012A |
|
34 |
34 |
$1K |
| 0011A |
|
26 |
26 |
$671.04 |