| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,493 |
1,489 |
$42K |
| D1206 |
Topical application of fluoride varnish |
1,906 |
1,899 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
1,684 |
1,680 |
$38K |
| D0272 |
Bitewings - two radiographic images |
690 |
689 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
211 |
157 |
$13K |
| D1110 |
Prophylaxis - adult |
321 |
321 |
$12K |
| D0603 |
|
1,105 |
1,105 |
$11K |
| D1330 |
|
1,548 |
1,548 |
$9K |
| D0274 |
Bitewings - four radiographic images |
223 |
223 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
130 |
97 |
$7K |
| D0330 |
Panoramic radiographic image |
145 |
145 |
$6K |
| D1351 |
Sealant - per tooth |
161 |
42 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
180 |
180 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
76 |
67 |
$4K |
| D1310 |
|
226 |
226 |
$3K |
| D0240 |
|
97 |
87 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
214 |
213 |
$2K |
| D0602 |
|
161 |
161 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
48 |
48 |
$1K |
| D0601 |
|
24 |
24 |
$240.00 |