| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,863 |
1,181 |
$31K |
| D0330 |
Panoramic radiographic image |
1,461 |
712 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
206 |
100 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,003 |
502 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,714 |
1,033 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
933 |
397 |
$14K |
| D0272 |
Bitewings - two radiographic images |
1,210 |
745 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
62 |
26 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
138 |
136 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
35 |
14 |
$1K |
| D1351 |
Sealant - per tooth |
55 |
12 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
136 |
16 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
32 |
13 |
$58.48 |