| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
510 |
474 |
$23K |
| D1206 |
Topical application of fluoride varnish |
517 |
483 |
$22K |
| D1351 |
Sealant - per tooth |
1,342 |
187 |
$21K |
| D0330 |
Panoramic radiographic image |
535 |
498 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
599 |
552 |
$17K |
| D0274 |
Bitewings - four radiographic images |
681 |
630 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
306 |
139 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
507 |
476 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
258 |
103 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
659 |
596 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,473 |
723 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
99 |
94 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
81 |
42 |
$2K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$249.81 |