| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,183 |
1,019 |
$30K |
| D1206 |
Topical application of fluoride varnish |
679 |
585 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
528 |
458 |
$12K |
| D0274 |
Bitewings - four radiographic images |
482 |
411 |
$11K |
| D0330 |
Panoramic radiographic image |
299 |
243 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
306 |
248 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
238 |
205 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
62 |
37 |
$5K |
| D1351 |
Sealant - per tooth |
305 |
28 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
28 |
14 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
15 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
134 |
101 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
41 |
30 |
$488.55 |
| D0350 |
|
17 |
13 |
$300.49 |