| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
927 |
927 |
$46K |
| D1206 |
Topical application of fluoride varnish |
1,064 |
1,064 |
$30K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
146 |
65 |
$24K |
| D3120 |
|
487 |
101 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
84 |
39 |
$11K |
| D1351 |
Sealant - per tooth |
259 |
64 |
$9K |
| D9248 |
|
61 |
61 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
248 |
248 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
155 |
155 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
59 |
24 |
$5K |
| D0272 |
Bitewings - two radiographic images |
167 |
167 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
44 |
44 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
83 |
82 |
$1K |
| D1110 |
Prophylaxis - adult |
15 |
15 |
$673.22 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$421.63 |
| D0350 |
|
12 |
12 |
$403.44 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
13 |
$160.30 |