| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
3,057 |
3,006 |
$118K |
| D1120 |
Prophylaxis - child |
2,217 |
2,175 |
$112K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
566 |
427 |
$108K |
| D0330 |
Panoramic radiographic image |
1,002 |
986 |
$95K |
| D1110 |
Prophylaxis - adult |
972 |
961 |
$74K |
| D0120 |
Periodic oral evaluation - established patient |
1,647 |
1,623 |
$66K |
| D0274 |
Bitewings - four radiographic images |
934 |
928 |
$46K |
| D0272 |
Bitewings - two radiographic images |
1,328 |
1,311 |
$43K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
630 |
617 |
$40K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
282 |
229 |
$35K |
| D7140 |
Extraction, erupted tooth or exposed root |
282 |
170 |
$33K |
| D0140 |
Limited oral evaluation - problem focused |
277 |
264 |
$17K |
| D1351 |
Sealant - per tooth |
92 |
17 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
144 |
142 |
$4K |