| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
713 |
687 |
$32K |
| D1120 |
Prophylaxis - child |
497 |
476 |
$23K |
| D1206 |
Topical application of fluoride varnish |
834 |
808 |
$19K |
| D1110 |
Prophylaxis - adult |
354 |
343 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
157 |
111 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
112 |
85 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
135 |
135 |
$8K |
| D0274 |
Bitewings - four radiographic images |
242 |
240 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
514 |
487 |
$7K |
| D0330 |
Panoramic radiographic image |
83 |
83 |
$6K |
| D1351 |
Sealant - per tooth |
136 |
49 |
$5K |
| D0272 |
Bitewings - two radiographic images |
303 |
290 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
72 |
66 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
15 |
13 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
78 |
70 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
178 |
173 |
$2K |