| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
176 |
176 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
363 |
359 |
$7K |
| D1206 |
Topical application of fluoride varnish |
268 |
268 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
47 |
37 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
164 |
164 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
263 |
260 |
$5K |
| D1110 |
Prophylaxis - adult |
93 |
93 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
41 |
30 |
$4K |
| D0272 |
Bitewings - two radiographic images |
136 |
136 |
$4K |
| D0330 |
Panoramic radiographic image |
60 |
60 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
95 |
95 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
83 |
81 |
$3K |
| D0274 |
Bitewings - four radiographic images |
74 |
74 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
29 |
26 |
$3K |