| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,331 |
2,331 |
$58K |
| D1351 |
Sealant - per tooth |
4,100 |
768 |
$53K |
| D0120 |
Periodic oral evaluation - established patient |
2,476 |
2,476 |
$52K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,662 |
2,662 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
732 |
548 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
496 |
366 |
$9K |
| D0273 |
|
1,023 |
1,022 |
$6K |
| D0330 |
Panoramic radiographic image |
249 |
249 |
$5K |
| D0603 |
|
400 |
400 |
$4K |
| D1110 |
Prophylaxis - adult |
62 |
62 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
111 |
85 |
$1K |
| D0602 |
|
94 |
94 |
$940.00 |
| D0272 |
Bitewings - two radiographic images |
65 |
65 |
$367.75 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
47 |
47 |
$276.00 |