| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,382 |
2,366 |
$78K |
| D0120 |
Periodic oral evaluation - established patient |
2,735 |
2,726 |
$60K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
775 |
413 |
$42K |
| D1206 |
Topical application of fluoride varnish |
2,513 |
2,503 |
$34K |
| D1110 |
Prophylaxis - adult |
578 |
578 |
$19K |
| D1351 |
Sealant - per tooth |
802 |
244 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
684 |
639 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,675 |
1,603 |
$9K |
| D0272 |
Bitewings - two radiographic images |
792 |
788 |
$7K |
| D0274 |
Bitewings - four radiographic images |
406 |
405 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,340 |
1,314 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
108 |
66 |
$5K |
| D0240 |
|
196 |
194 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
279 |
279 |
$3K |
| D0330 |
Panoramic radiographic image |
109 |
109 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
59 |
39 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
35 |
24 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
68 |
68 |
$1K |