| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
451 |
451 |
$19K |
| D1351 |
Sealant - per tooth |
298 |
106 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
509 |
509 |
$15K |
| D7140 |
Extraction, erupted tooth or exposed root |
208 |
122 |
$14K |
| D1110 |
Prophylaxis - adult |
229 |
229 |
$10K |
| D1206 |
Topical application of fluoride varnish |
349 |
349 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
321 |
321 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
119 |
81 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
176 |
105 |
$8K |
| D0274 |
Bitewings - four radiographic images |
357 |
357 |
$7K |
| D0330 |
Panoramic radiographic image |
239 |
239 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
533 |
532 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
510 |
510 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
56 |
56 |
$2K |
| D2330 |
|
23 |
13 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
54 |
54 |
$1K |
| D0272 |
Bitewings - two radiographic images |
91 |
91 |
$1K |