| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
6,835 |
6,116 |
$237K |
| D1120 |
Prophylaxis - child |
5,385 |
4,814 |
$226K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,777 |
1,164 |
$190K |
| D0120 |
Periodic oral evaluation - established patient |
5,879 |
5,239 |
$121K |
| D8670 |
Periodic orthodontic treatment visit |
1,038 |
885 |
$85K |
| D1110 |
Prophylaxis - adult |
1,367 |
1,231 |
$83K |
| D7140 |
Extraction, erupted tooth or exposed root |
970 |
527 |
$82K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
706 |
536 |
$54K |
| D0274 |
Bitewings - four radiographic images |
1,253 |
1,149 |
$43K |
| D1351 |
Sealant - per tooth |
1,234 |
343 |
$41K |
| D0272 |
Bitewings - two radiographic images |
1,432 |
1,234 |
$34K |
| D0330 |
Panoramic radiographic image |
541 |
511 |
$32K |
| D1310 |
|
835 |
686 |
$28K |
| D1330 |
|
832 |
683 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
590 |
544 |
$21K |
| D9920 |
|
89 |
86 |
$2K |
| D0240 |
|
25 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
44 |
38 |
$660.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$429.00 |