| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
894 |
859 |
$30K |
| D1206 |
Topical application of fluoride varnish |
1,160 |
1,116 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
590 |
583 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
589 |
558 |
$16K |
| D0272 |
Bitewings - two radiographic images |
596 |
562 |
$12K |
| D1110 |
Prophylaxis - adult |
210 |
205 |
$12K |
| D0330 |
Panoramic radiographic image |
115 |
113 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
77 |
28 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
50 |
40 |
$4K |
| D0274 |
Bitewings - four radiographic images |
89 |
87 |
$3K |
| D1351 |
Sealant - per tooth |
35 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
20 |
20 |
$900.00 |
| D0220 |
Intraoral - periapical first radiographic image |
63 |
61 |
$885.58 |