| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,260 |
1,218 |
$64K |
| D0120 |
Periodic oral evaluation - established patient |
2,216 |
2,163 |
$64K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,308 |
2,256 |
$38K |
| D0272 |
Bitewings - two radiographic images |
1,314 |
1,283 |
$28K |
| D1120 |
Prophylaxis - child |
853 |
842 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
1,073 |
1,018 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
104 |
51 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
419 |
409 |
$8K |
| D1351 |
Sealant - per tooth |
308 |
25 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
42 |
27 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
35 |
13 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
40 |
27 |
$567.82 |