| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,622 |
1,583 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
1,490 |
1,450 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,133 |
1,102 |
$14K |
| D0272 |
Bitewings - two radiographic images |
832 |
816 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
101 |
55 |
$7K |
| D1206 |
Topical application of fluoride varnish |
324 |
324 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
144 |
143 |
$4K |
| D1351 |
Sealant - per tooth |
129 |
54 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
287 |
272 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
40 |
25 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
68 |
66 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
13 |
$870.57 |
| D0230 |
Intraoral - periapical each additional radiographic image |
97 |
42 |
$414.15 |