| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
11,504 |
11,198 |
$294K |
| D1110 |
Prophylaxis - adult |
5,261 |
5,121 |
$198K |
| D1120 |
Prophylaxis - child |
6,105 |
5,951 |
$165K |
| D1206 |
Topical application of fluoride varnish |
6,151 |
6,024 |
$101K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,425 |
4,268 |
$70K |
| D0274 |
Bitewings - four radiographic images |
1,699 |
1,642 |
$53K |
| D1351 |
Sealant - per tooth |
1,683 |
509 |
$47K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
565 |
391 |
$43K |
| D0330 |
Panoramic radiographic image |
734 |
711 |
$40K |
| D0272 |
Bitewings - two radiographic images |
1,722 |
1,683 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
188 |
115 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
312 |
310 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
426 |
411 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
86 |
51 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
43 |
43 |
$2K |