| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,435 |
1,435 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
1,681 |
1,681 |
$36K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
442 |
301 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,834 |
1,834 |
$20K |
| D1110 |
Prophylaxis - adult |
439 |
439 |
$19K |
| D0272 |
Bitewings - two radiographic images |
763 |
763 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
676 |
669 |
$7K |
| D1351 |
Sealant - per tooth |
209 |
92 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
520 |
481 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
123 |
86 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
103 |
75 |
$4K |
| D0274 |
Bitewings - four radiographic images |
175 |
175 |
$4K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
33 |
26 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
113 |
113 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
26 |
26 |
$273.38 |