| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,896 |
1,895 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
1,881 |
1,880 |
$32K |
| D1351 |
Sealant - per tooth |
2,616 |
551 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
507 |
362 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,118 |
2,118 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
440 |
305 |
$11K |
| D0273 |
|
1,166 |
1,166 |
$7K |
| D1110 |
Prophylaxis - adult |
55 |
54 |
$2K |
| D0330 |
Panoramic radiographic image |
151 |
151 |
$2K |
| D0603 |
|
214 |
214 |
$2K |
| D1206 |
Topical application of fluoride varnish |
46 |
46 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
79 |
79 |
$1K |
| D0602 |
|
120 |
120 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
89 |
61 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
13 |
$162.15 |
| D0601 |
|
15 |
15 |
$150.00 |