| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
476 |
476 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
166 |
74 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
636 |
636 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
207 |
106 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,321 |
620 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
471 |
471 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
437 |
430 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
792 |
767 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
86 |
48 |
$6K |
| D1110 |
Prophylaxis - adult |
84 |
84 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
148 |
145 |
$3K |
| D1351 |
Sealant - per tooth |
64 |
20 |
$2K |
| D0272 |
Bitewings - two radiographic images |
62 |
62 |
$1K |
| D0274 |
Bitewings - four radiographic images |
43 |
43 |
$1K |