| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,414 |
1,325 |
$57K |
| D0120 |
Periodic oral evaluation - established patient |
1,180 |
1,113 |
$32K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,252 |
1,167 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
646 |
595 |
$14K |
| D1351 |
Sealant - per tooth |
84 |
46 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
78 |
39 |
$5K |
| D0274 |
Bitewings - four radiographic images |
182 |
175 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
282 |
266 |
$2K |
| D0272 |
Bitewings - two radiographic images |
104 |
100 |
$968.20 |
| D1110 |
Prophylaxis - adult |
30 |
29 |
$847.60 |
| D7140 |
Extraction, erupted tooth or exposed root |
23 |
16 |
$821.52 |
| D0140 |
Limited oral evaluation - problem focused |
31 |
31 |
$540.37 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$271.20 |
| D0230 |
Intraoral - periapical each additional radiographic image |
32 |
31 |
$161.28 |