| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
3,246 |
2,866 |
$112K |
| D1120 |
Prophylaxis - child |
2,240 |
2,096 |
$94K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,035 |
550 |
$78K |
| D0120 |
Periodic oral evaluation - established patient |
2,667 |
2,320 |
$55K |
| D1110 |
Prophylaxis - adult |
972 |
817 |
$39K |
| D0274 |
Bitewings - four radiographic images |
1,439 |
1,190 |
$35K |
| D0330 |
Panoramic radiographic image |
399 |
380 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
521 |
474 |
$16K |
| D1310 |
|
637 |
540 |
$14K |
| D1330 |
|
644 |
547 |
$12K |
| D1351 |
Sealant - per tooth |
556 |
109 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
55 |
26 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
84 |
79 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
47 |
30 |
$2K |
| D0272 |
Bitewings - two radiographic images |
101 |
88 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
34 |
13 |
$850.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
12 |
$770.00 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$168.00 |