| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
870 |
588 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
577 |
363 |
$14K |
| D1351 |
Sealant - per tooth |
622 |
55 |
$8K |
| D0330 |
Panoramic radiographic image |
310 |
156 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
424 |
302 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
52 |
16 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
119 |
14 |
$3K |
| D0274 |
Bitewings - four radiographic images |
247 |
133 |
$3K |
| D1206 |
Topical application of fluoride varnish |
217 |
102 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
15 |
13 |
$460.07 |
| D0220 |
Intraoral - periapical first radiographic image |
33 |
30 |
$348.12 |
| D0272 |
Bitewings - two radiographic images |
25 |
24 |
$319.48 |