| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,307 |
1,304 |
$29K |
| D1206 |
Topical application of fluoride varnish |
1,352 |
1,351 |
$27K |
| D1120 |
Prophylaxis - child |
1,009 |
1,007 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
299 |
219 |
$18K |
| D1110 |
Prophylaxis - adult |
457 |
456 |
$17K |
| D1351 |
Sealant - per tooth |
483 |
99 |
$14K |
| D0272 |
Bitewings - two radiographic images |
595 |
593 |
$11K |
| D0274 |
Bitewings - four radiographic images |
356 |
356 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
169 |
130 |
$9K |
| D0330 |
Panoramic radiographic image |
178 |
178 |
$7K |
| D0603 |
|
483 |
483 |
$5K |
| D1330 |
|
571 |
571 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
115 |
115 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
20 |
15 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
132 |
131 |
$1K |
| D0240 |
|
26 |
24 |
$453.38 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$369.00 |
| D0602 |
|
27 |
27 |
$260.00 |