| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,949 |
1,940 |
$60K |
| D1206 |
Topical application of fluoride varnish |
1,393 |
1,391 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
1,543 |
1,530 |
$33K |
| D0220 |
Intraoral - periapical first radiographic image |
1,301 |
1,291 |
$15K |
| D0272 |
Bitewings - two radiographic images |
856 |
855 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
665 |
654 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,127 |
1,125 |
$6K |
| D1351 |
Sealant - per tooth |
132 |
57 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
345 |
335 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
102 |
82 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
175 |
175 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
31 |
26 |
$2K |
| D1354 |
|
89 |
25 |
$2K |
| D0240 |
|
15 |
15 |
$359.99 |