| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
780 |
779 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
193 |
172 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
641 |
640 |
$14K |
| D1110 |
Prophylaxis - adult |
267 |
267 |
$11K |
| D1206 |
Topical application of fluoride varnish |
427 |
426 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
436 |
435 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
738 |
729 |
$8K |
| D0274 |
Bitewings - four radiographic images |
351 |
351 |
$8K |
| D1351 |
Sealant - per tooth |
78 |
55 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
168 |
160 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
658 |
655 |
$4K |
| D0272 |
Bitewings - two radiographic images |
264 |
262 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
289 |
289 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
51 |
45 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
133 |
130 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
27 |
26 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$979.70 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$272.00 |