| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
2,346 |
2,330 |
$48K |
| D0120 |
Periodic oral evaluation - established patient |
2,097 |
2,090 |
$47K |
| D1120 |
Prophylaxis - child |
1,596 |
1,588 |
$46K |
| D1110 |
Prophylaxis - adult |
630 |
629 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
383 |
290 |
$22K |
| D0272 |
Bitewings - two radiographic images |
905 |
899 |
$17K |
| D1351 |
Sealant - per tooth |
562 |
134 |
$16K |
| D0274 |
Bitewings - four radiographic images |
483 |
481 |
$14K |
| D1330 |
|
1,721 |
1,717 |
$12K |
| D0603 |
|
926 |
925 |
$9K |
| D0330 |
Panoramic radiographic image |
168 |
166 |
$7K |
| D1310 |
|
572 |
569 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
106 |
83 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
180 |
178 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
36 |
28 |
$2K |
| D0602 |
|
135 |
135 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
139 |
139 |
$1K |
| D0240 |
|
69 |
50 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$341.00 |