| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,031 |
1,026 |
$41K |
| D1206 |
Topical application of fluoride varnish |
1,617 |
1,607 |
$41K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
283 |
198 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
1,251 |
1,243 |
$39K |
| D1110 |
Prophylaxis - adult |
668 |
661 |
$36K |
| D0330 |
Panoramic radiographic image |
449 |
434 |
$30K |
| D7140 |
Extraction, erupted tooth or exposed root |
350 |
160 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
358 |
354 |
$19K |
| D0272 |
Bitewings - two radiographic images |
515 |
514 |
$14K |
| D0274 |
Bitewings - four radiographic images |
305 |
299 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
86 |
72 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
299 |
290 |
$5K |
| D1351 |
Sealant - per tooth |
95 |
27 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
44 |
37 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
18 |
14 |
$378.00 |