| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,062 |
1,061 |
$37K |
| D1206 |
Topical application of fluoride varnish |
740 |
739 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
933 |
932 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
153 |
106 |
$3K |
| D1351 |
Sealant - per tooth |
292 |
55 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
143 |
143 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
74 |
46 |
$2K |
| D0330 |
Panoramic radiographic image |
133 |
133 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
425 |
425 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
57 |
34 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
207 |
207 |
$1K |
| D0273 |
|
192 |
192 |
$747.33 |
| D0230 |
Intraoral - periapical each additional radiographic image |
173 |
173 |
$567.70 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$539.50 |
| D0274 |
Bitewings - four radiographic images |
25 |
25 |
$330.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$126.00 |