| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
388 |
380 |
$18K |
| D1110 |
Prophylaxis - adult |
186 |
182 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
75 |
49 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
94 |
69 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
299 |
295 |
$14K |
| D1120 |
Prophylaxis - child |
213 |
210 |
$13K |
| D0330 |
Panoramic radiographic image |
99 |
96 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
122 |
120 |
$10K |
| D0274 |
Bitewings - four radiographic images |
163 |
160 |
$10K |
| D1351 |
Sealant - per tooth |
185 |
64 |
$9K |
| D0272 |
Bitewings - two radiographic images |
156 |
156 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
97 |
93 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
16 |
12 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$948.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
19 |
15 |
$620.00 |