| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,558 |
2,959 |
$87K |
| D1206 |
Topical application of fluoride varnish |
3,411 |
2,830 |
$68K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,351 |
1,775 |
$67K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
781 |
308 |
$61K |
| D0140 |
Limited oral evaluation - problem focused |
1,771 |
1,199 |
$51K |
| D1351 |
Sealant - per tooth |
1,683 |
276 |
$39K |
| D0330 |
Panoramic radiographic image |
821 |
655 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
1,214 |
1,157 |
$32K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
518 |
231 |
$29K |
| D0274 |
Bitewings - four radiographic images |
770 |
646 |
$19K |
| D7140 |
Extraction, erupted tooth or exposed root |
322 |
145 |
$18K |
| D0272 |
Bitewings - two radiographic images |
718 |
542 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
700 |
515 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
43 |
27 |
$299.36 |