| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
430 |
405 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
244 |
120 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
377 |
357 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
160 |
132 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
299 |
283 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
218 |
200 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
160 |
126 |
$5K |
| D1351 |
Sealant - per tooth |
41 |
14 |
$3K |
| D0274 |
Bitewings - four radiographic images |
250 |
237 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
656 |
609 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
221 |
203 |
$3K |
| D1110 |
Prophylaxis - adult |
53 |
48 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
471 |
424 |
$2K |
| D0330 |
Panoramic radiographic image |
90 |
82 |
$1K |
| D0272 |
Bitewings - two radiographic images |
136 |
125 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
15 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
67 |
66 |
$727.90 |