| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,146 |
2,132 |
$64K |
| D0120 |
Periodic oral evaluation - established patient |
1,848 |
1,847 |
$44K |
| D1351 |
Sealant - per tooth |
1,534 |
319 |
$26K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
439 |
288 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,071 |
2,057 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
182 |
115 |
$8K |
| D0603 |
|
648 |
648 |
$6K |
| D0273 |
|
386 |
386 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
145 |
144 |
$3K |
| D0602 |
|
169 |
169 |
$1K |
| D0272 |
Bitewings - two radiographic images |
207 |
201 |
$1K |
| D0274 |
Bitewings - four radiographic images |
113 |
113 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
243 |
243 |
$1K |
| D1206 |
Topical application of fluoride varnish |
97 |
96 |
$790.25 |
| D0230 |
Intraoral - periapical each additional radiographic image |
188 |
188 |
$543.00 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$490.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
13 |
12 |
$486.45 |