| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,108 |
2,099 |
$58K |
| D1206 |
Topical application of fluoride varnish |
2,618 |
2,608 |
$53K |
| D0120 |
Periodic oral evaluation - established patient |
2,245 |
2,235 |
$50K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
335 |
240 |
$20K |
| D0272 |
Bitewings - two radiographic images |
1,031 |
1,029 |
$20K |
| D1110 |
Prophylaxis - adult |
472 |
471 |
$18K |
| D0603 |
|
1,432 |
1,431 |
$14K |
| D0330 |
Panoramic radiographic image |
300 |
300 |
$13K |
| D1330 |
|
1,992 |
1,991 |
$11K |
| D0274 |
Bitewings - four radiographic images |
347 |
346 |
$11K |
| D1351 |
Sealant - per tooth |
332 |
82 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
377 |
377 |
$9K |
| D0240 |
|
326 |
234 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
79 |
57 |
$4K |
| D1310 |
|
270 |
270 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
236 |
234 |
$2K |
| D0602 |
|
207 |
207 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
43 |
38 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
61 |
60 |
$2K |
| D0601 |
|
27 |
27 |
$270.00 |