| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,923 |
2,951 |
$80K |
| D1351 |
Sealant - per tooth |
3,140 |
512 |
$55K |
| D0274 |
Bitewings - four radiographic images |
1,971 |
1,445 |
$40K |
| D1206 |
Topical application of fluoride varnish |
2,213 |
1,701 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
1,479 |
1,268 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,805 |
1,066 |
$30K |
| D0140 |
Limited oral evaluation - problem focused |
1,039 |
798 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,209 |
806 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
113 |
12 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
17 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
65 |
53 |
$684.56 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$585.66 |
| D0272 |
Bitewings - two radiographic images |
72 |
14 |
$244.59 |