| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,212 |
2,212 |
$77K |
| D0120 |
Periodic oral evaluation - established patient |
2,359 |
2,359 |
$53K |
| D1351 |
Sealant - per tooth |
1,655 |
508 |
$52K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,808 |
1,808 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
364 |
226 |
$21K |
| D0272 |
Bitewings - two radiographic images |
1,603 |
1,603 |
$19K |
| D1206 |
Topical application of fluoride varnish |
656 |
656 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,480 |
1,477 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,518 |
1,514 |
$9K |
| D9920 |
|
440 |
405 |
$7K |
| D1110 |
Prophylaxis - adult |
119 |
119 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
49 |
37 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
55 |
55 |
$1K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
15 |
12 |
$1K |
| D0274 |
Bitewings - four radiographic images |
44 |
44 |
$949.24 |
| D7140 |
Extraction, erupted tooth or exposed root |
13 |
12 |
$679.00 |
| D0330 |
Panoramic radiographic image |
24 |
24 |
$651.88 |