| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,061 |
1,052 |
$45K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
380 |
155 |
$42K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
728 |
715 |
$34K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,445 |
1,431 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
937 |
924 |
$26K |
| D1110 |
Prophylaxis - adult |
442 |
427 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
157 |
77 |
$13K |
| D1351 |
Sealant - per tooth |
325 |
63 |
$11K |
| D0330 |
Panoramic radiographic image |
230 |
228 |
$10K |
| D0274 |
Bitewings - four radiographic images |
386 |
378 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
59 |
36 |
$6K |
| D0272 |
Bitewings - two radiographic images |
193 |
193 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
68 |
68 |
$3K |
| D1330 |
|
49 |
49 |
$294.00 |
| D0220 |
Intraoral - periapical first radiographic image |
30 |
30 |
$252.00 |