| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
522 |
419 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
533 |
416 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
197 |
117 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
146 |
102 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
173 |
141 |
$4K |
| D0274 |
Bitewings - four radiographic images |
155 |
117 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
121 |
95 |
$2K |
| D1110 |
Prophylaxis - adult |
68 |
47 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
37 |
20 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
28 |
14 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
188 |
148 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
68 |
49 |
$972.00 |
| D0272 |
Bitewings - two radiographic images |
82 |
65 |
$752.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
136 |
109 |
$699.20 |