| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
4,091 |
4,091 |
$97K |
| D1120 |
Prophylaxis - child |
2,673 |
2,673 |
$89K |
| D1110 |
Prophylaxis - adult |
1,541 |
1,541 |
$66K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
806 |
526 |
$63K |
| D1351 |
Sealant - per tooth |
1,335 |
430 |
$50K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,300 |
3,300 |
$41K |
| D0274 |
Bitewings - four radiographic images |
1,326 |
1,326 |
$33K |
| D1206 |
Topical application of fluoride varnish |
928 |
928 |
$26K |
| D0330 |
Panoramic radiographic image |
700 |
700 |
$19K |
| D0272 |
Bitewings - two radiographic images |
817 |
817 |
$12K |
| D2394 |
|
77 |
55 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
100 |
72 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
400 |
399 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
64 |
42 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
53 |
53 |
$1K |