| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
757 |
757 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
1,011 |
1,011 |
$29K |
| D1206 |
Topical application of fluoride varnish |
1,054 |
1,054 |
$26K |
| D1110 |
Prophylaxis - adult |
308 |
308 |
$18K |
| D1351 |
Sealant - per tooth |
352 |
78 |
$12K |
| D0330 |
Panoramic radiographic image |
121 |
121 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
33 |
15 |
$4K |
| D0274 |
Bitewings - four radiographic images |
154 |
154 |
$3K |
| D1330 |
|
533 |
533 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
43 |
43 |
$2K |
| D0272 |
Bitewings - two radiographic images |
119 |
119 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
26 |
25 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$108.00 |