| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,175 |
1,173 |
$50K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
332 |
152 |
$29K |
| D1206 |
Topical application of fluoride varnish |
1,222 |
1,220 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
867 |
865 |
$23K |
| D0272 |
Bitewings - two radiographic images |
729 |
727 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
450 |
450 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,128 |
1,119 |
$17K |
| D1351 |
Sealant - per tooth |
429 |
80 |
$14K |
| D0274 |
Bitewings - four radiographic images |
350 |
349 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,069 |
1,053 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
13 |
$1K |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$402.60 |