| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,296 |
3,900 |
$108K |
| D1110 |
Prophylaxis - adult |
2,976 |
2,690 |
$96K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,648 |
1,031 |
$96K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,384 |
923 |
$95K |
| D0120 |
Periodic oral evaluation - established patient |
5,016 |
4,564 |
$84K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,834 |
4,337 |
$61K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,591 |
2,277 |
$54K |
| D0330 |
Panoramic radiographic image |
1,130 |
1,002 |
$40K |
| D0274 |
Bitewings - four radiographic images |
2,031 |
1,796 |
$39K |
| D0272 |
Bitewings - two radiographic images |
2,186 |
1,966 |
$33K |
| D1206 |
Topical application of fluoride varnish |
1,931 |
1,782 |
$31K |
| D1354 |
|
889 |
265 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
480 |
420 |
$12K |
| D1351 |
Sealant - per tooth |
595 |
139 |
$11K |
| D1999 |
|
1,085 |
929 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
46 |
25 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
54 |
50 |
$490.05 |