| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,013 |
1,013 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
1,160 |
1,160 |
$33K |
| D1206 |
Topical application of fluoride varnish |
1,097 |
1,097 |
$33K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
110 |
66 |
$9K |
| D0272 |
Bitewings - two radiographic images |
479 |
479 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
549 |
549 |
$8K |
| D1110 |
Prophylaxis - adult |
88 |
88 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
600 |
599 |
$5K |
| D1351 |
Sealant - per tooth |
92 |
26 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
16 |
12 |
$720.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$480.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
25 |
25 |
$350.00 |