| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
3,248 |
1,974 |
$112K |
| D1120 |
Prophylaxis - child |
2,595 |
1,592 |
$101K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,421 |
682 |
$99K |
| D1351 |
Sealant - per tooth |
2,685 |
395 |
$53K |
| D0120 |
Periodic oral evaluation - established patient |
2,153 |
1,196 |
$40K |
| D1354 |
|
1,357 |
328 |
$34K |
| D0330 |
Panoramic radiographic image |
691 |
426 |
$33K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
645 |
343 |
$33K |
| D0274 |
Bitewings - four radiographic images |
973 |
550 |
$23K |
| D0272 |
Bitewings - two radiographic images |
1,101 |
626 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
652 |
388 |
$19K |
| D1110 |
Prophylaxis - adult |
394 |
230 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
344 |
228 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
479 |
302 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
107 |
42 |
$4K |
| D9310 |
|
38 |
38 |
$1K |