| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,293 |
2,224 |
$126K |
| D1206 |
Topical application of fluoride varnish |
2,711 |
2,634 |
$117K |
| D0330 |
Panoramic radiographic image |
647 |
621 |
$61K |
| D0120 |
Periodic oral evaluation - established patient |
1,428 |
1,384 |
$55K |
| D1110 |
Prophylaxis - adult |
679 |
660 |
$51K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
279 |
195 |
$50K |
| D0272 |
Bitewings - two radiographic images |
1,253 |
1,227 |
$41K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
593 |
564 |
$36K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
209 |
169 |
$20K |
| D0274 |
Bitewings - four radiographic images |
315 |
310 |
$15K |
| D1351 |
Sealant - per tooth |
323 |
78 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
82 |
39 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
93 |
89 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
122 |
121 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
14 |
14 |
$617.00 |
| D0210 |
Intraoral - complete series of radiographic images |
30 |
24 |
$364.00 |