| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
859 |
603 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
698 |
534 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
798 |
547 |
$13K |
| D1351 |
Sealant - per tooth |
480 |
130 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
252 |
159 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
328 |
179 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
583 |
395 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
279 |
135 |
$8K |
| D1110 |
Prophylaxis - adult |
302 |
209 |
$7K |
| D0274 |
Bitewings - four radiographic images |
482 |
353 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
279 |
210 |
$4K |
| D0272 |
Bitewings - two radiographic images |
335 |
213 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
437 |
319 |
$2K |
| D0330 |
Panoramic radiographic image |
20 |
19 |
$1K |
| D1206 |
Topical application of fluoride varnish |
65 |
60 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
181 |
110 |
$741.00 |
| D0210 |
Intraoral - complete series of radiographic images |
21 |
20 |
$424.59 |