| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,015 |
1,014 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
1,080 |
1,080 |
$30K |
| D1351 |
Sealant - per tooth |
758 |
129 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
269 |
143 |
$24K |
| D1206 |
Topical application of fluoride varnish |
1,159 |
1,158 |
$24K |
| D0272 |
Bitewings - two radiographic images |
819 |
819 |
$23K |
| D0274 |
Bitewings - four radiographic images |
243 |
243 |
$10K |
| D0330 |
Panoramic radiographic image |
90 |
90 |
$7K |
| D1110 |
Prophylaxis - adult |
79 |
79 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
54 |
39 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
69 |
69 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
25 |
13 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
29 |
29 |
$461.38 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$391.42 |