| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,521 |
5,214 |
$227K |
| D1206 |
Topical application of fluoride varnish |
6,102 |
5,769 |
$210K |
| D0120 |
Periodic oral evaluation - established patient |
5,889 |
5,575 |
$117K |
| D0272 |
Bitewings - two radiographic images |
1,500 |
1,411 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
285 |
160 |
$30K |
| D1110 |
Prophylaxis - adult |
415 |
390 |
$24K |
| D7140 |
Extraction, erupted tooth or exposed root |
249 |
138 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
395 |
347 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
155 |
111 |
$12K |
| D0240 |
|
233 |
211 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
245 |
218 |
$9K |
| D1351 |
Sealant - per tooth |
227 |
48 |
$7K |
| D0274 |
Bitewings - four radiographic images |
39 |
39 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
59 |
56 |
$870.00 |