| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
7,908 |
7,606 |
$322K |
| D1351 |
Sealant - per tooth |
3,663 |
1,712 |
$240K |
| D1206 |
Topical application of fluoride varnish |
7,435 |
7,184 |
$192K |
| D0120 |
Periodic oral evaluation - established patient |
6,810 |
6,581 |
$189K |
| D0210 |
Intraoral - complete series of radiographic images |
1,224 |
1,143 |
$39K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
514 |
320 |
$36K |
| D0274 |
Bitewings - four radiographic images |
1,291 |
1,260 |
$23K |
| D7140 |
Extraction, erupted tooth or exposed root |
176 |
103 |
$10K |
| D0272 |
Bitewings - two radiographic images |
936 |
907 |
$9K |
| D0330 |
Panoramic radiographic image |
254 |
246 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
52 |
37 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
204 |
198 |
$3K |
| D2394 |
|
13 |
13 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
35 |
35 |
$910.00 |
| D0220 |
Intraoral - periapical first radiographic image |
133 |
131 |
$811.20 |