| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
295 |
295 |
$10K |
| D1206 |
Topical application of fluoride varnish |
419 |
418 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
292 |
225 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
306 |
304 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
74 |
64 |
$5K |
| D0330 |
Panoramic radiographic image |
93 |
74 |
$4K |
| D1110 |
Prophylaxis - adult |
82 |
80 |
$4K |
| D1351 |
Sealant - per tooth |
68 |
29 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
88 |
78 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
46 |
27 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
117 |
76 |
$2K |
| D0272 |
Bitewings - two radiographic images |
86 |
86 |
$2K |
| D0274 |
Bitewings - four radiographic images |
58 |
57 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
187 |
124 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
15 |
15 |
$302.25 |