| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
302 |
302 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
333 |
333 |
$10K |
| D1206 |
Topical application of fluoride varnish |
273 |
273 |
$7K |
| D0274 |
Bitewings - four radiographic images |
237 |
237 |
$4K |
| D1110 |
Prophylaxis - adult |
61 |
61 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
53 |
45 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
379 |
378 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
76 |
76 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
350 |
350 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
63 |
61 |
$1K |
| D0272 |
Bitewings - two radiographic images |
81 |
81 |
$887.20 |
| D7140 |
Extraction, erupted tooth or exposed root |
14 |
12 |
$856.80 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$354.90 |