| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
652 |
608 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
809 |
760 |
$21K |
| D1206 |
Topical application of fluoride varnish |
329 |
302 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
56 |
51 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
37 |
27 |
$2K |
| D0274 |
Bitewings - four radiographic images |
95 |
90 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
173 |
166 |
$912.80 |
| D0140 |
Limited oral evaluation - problem focused |
16 |
16 |
$259.20 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
15 |
$252.60 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$122.20 |