| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
654 |
643 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
780 |
767 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
631 |
622 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
169 |
113 |
$9K |
| D1110 |
Prophylaxis - adult |
170 |
170 |
$7K |
| D0274 |
Bitewings - four radiographic images |
260 |
257 |
$4K |
| D4341 |
|
32 |
14 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
126 |
126 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
105 |
81 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
158 |
158 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
73 |
54 |
$3K |
| D0272 |
Bitewings - two radiographic images |
185 |
182 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
301 |
298 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
215 |
212 |
$896.80 |
| D0140 |
Limited oral evaluation - problem focused |
58 |
56 |
$810.00 |
| D2331 |
|
13 |
13 |
$570.90 |
| D0270 |
|
14 |
14 |
$78.40 |