| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,251 |
987 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
1,420 |
1,095 |
$36K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,244 |
981 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
355 |
240 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
400 |
286 |
$15K |
| D1351 |
Sealant - per tooth |
246 |
150 |
$15K |
| D7140 |
Extraction, erupted tooth or exposed root |
271 |
171 |
$12K |
| D0274 |
Bitewings - four radiographic images |
740 |
596 |
$11K |
| D1110 |
Prophylaxis - adult |
260 |
207 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
404 |
329 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
1,065 |
864 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,030 |
805 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
152 |
136 |
$2K |
| D0272 |
Bitewings - two radiographic images |
199 |
160 |
$2K |
| D1206 |
Topical application of fluoride varnish |
27 |
21 |
$598.00 |
| D1999 |
|
704 |
406 |
$0.00 |