| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,249 |
1,157 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
1,197 |
1,098 |
$31K |
| D1206 |
Topical application of fluoride varnish |
1,174 |
1,087 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
133 |
94 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
156 |
123 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
1,463 |
1,344 |
$8K |
| D0274 |
Bitewings - four radiographic images |
428 |
392 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
323 |
301 |
$7K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
88 |
58 |
$6K |
| D0272 |
Bitewings - two radiographic images |
632 |
582 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,374 |
1,249 |
$6K |
| D1110 |
Prophylaxis - adult |
142 |
121 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
98 |
70 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
98 |
96 |
$2K |
| D0270 |
|
166 |
157 |
$929.60 |