| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,195 |
3,195 |
$107K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,082 |
4,082 |
$85K |
| D0330 |
Panoramic radiographic image |
1,465 |
1,443 |
$70K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,833 |
1,818 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
1,669 |
1,669 |
$34K |
| D1110 |
Prophylaxis - adult |
686 |
685 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
328 |
245 |
$29K |
| D1351 |
Sealant - per tooth |
738 |
210 |
$24K |
| D7140 |
Extraction, erupted tooth or exposed root |
417 |
233 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
203 |
158 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
793 |
736 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
728 |
704 |
$13K |
| D0274 |
Bitewings - four radiographic images |
203 |
203 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
476 |
471 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
94 |
94 |
$2K |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$261.95 |