| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
4,529 |
4,051 |
$157K |
| D1120 |
Prophylaxis - child |
3,629 |
3,257 |
$152K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,446 |
939 |
$108K |
| D1351 |
Sealant - per tooth |
4,411 |
1,172 |
$88K |
| D0120 |
Periodic oral evaluation - established patient |
3,307 |
2,997 |
$67K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
854 |
547 |
$47K |
| D7111 |
|
830 |
450 |
$41K |
| D0274 |
Bitewings - four radiographic images |
1,672 |
1,474 |
$40K |
| D1110 |
Prophylaxis - adult |
755 |
673 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
986 |
834 |
$29K |
| D0272 |
Bitewings - two radiographic images |
1,536 |
1,366 |
$28K |
| D7140 |
Extraction, erupted tooth or exposed root |
576 |
292 |
$26K |
| D1354 |
|
1,006 |
335 |
$25K |
| D0330 |
Panoramic radiographic image |
493 |
405 |
$25K |
| D0140 |
Limited oral evaluation - problem focused |
649 |
592 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
434 |
400 |
$5K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
30 |
26 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
94 |
94 |
$2K |