| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,217 |
4,214 |
$95K |
| D0120 |
Periodic oral evaluation - established patient |
4,290 |
4,290 |
$79K |
| D1351 |
Sealant - per tooth |
7,130 |
1,290 |
$72K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,373 |
4,373 |
$27K |
| D0273 |
|
1,946 |
1,946 |
$11K |
| D0603 |
|
729 |
729 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
149 |
85 |
$7K |
| D0330 |
Panoramic radiographic image |
461 |
461 |
$6K |
| D1110 |
Prophylaxis - adult |
91 |
91 |
$2K |
| D0602 |
|
221 |
221 |
$2K |
| D1206 |
Topical application of fluoride varnish |
192 |
192 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
127 |
127 |
$759.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
97 |
66 |
$754.75 |
| D0272 |
Bitewings - two radiographic images |
95 |
95 |
$567.00 |
| D7111 |
|
19 |
12 |
$546.25 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$54.00 |