| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,052 |
6,043 |
$354K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,038 |
892 |
$93K |
| D1110 |
Prophylaxis - adult |
1,159 |
1,154 |
$93K |
| D0330 |
Panoramic radiographic image |
573 |
572 |
$54K |
| D1351 |
Sealant - per tooth |
4,036 |
862 |
$44K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
318 |
318 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
7,562 |
7,548 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
229 |
143 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
32 |
25 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
66 |
66 |
$2K |
| D0272 |
Bitewings - two radiographic images |
3,650 |
3,647 |
$2K |
| D9248 |
|
85 |
85 |
$820.36 |
| D7140 |
Extraction, erupted tooth or exposed root |
33 |
24 |
$527.12 |
| D0274 |
Bitewings - four radiographic images |
212 |
212 |
$106.03 |
| D0220 |
Intraoral - periapical first radiographic image |
212 |
210 |
$45.07 |
| D0240 |
|
215 |
209 |
$17.40 |
| D1206 |
Topical application of fluoride varnish |
18 |
18 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
6,795 |
6,781 |
$-770.56 |