| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
310 |
287 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
353 |
318 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
298 |
275 |
$8K |
| D1351 |
Sealant - per tooth |
63 |
38 |
$5K |
| D0274 |
Bitewings - four radiographic images |
219 |
192 |
$3K |
| D1110 |
Prophylaxis - adult |
69 |
58 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
107 |
96 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
327 |
289 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
312 |
268 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
13 |
13 |
$866.70 |
| D7140 |
Extraction, erupted tooth or exposed root |
13 |
12 |
$653.74 |
| D0272 |
Bitewings - two radiographic images |
68 |
61 |
$611.00 |
| D1999 |
|
145 |
129 |
$0.00 |