| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
785 |
768 |
$31K |
| D1206 |
Topical application of fluoride varnish |
631 |
619 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
535 |
519 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
234 |
232 |
$5K |
| D0272 |
Bitewings - two radiographic images |
180 |
176 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
14 |
$1K |
| D0274 |
Bitewings - four radiographic images |
61 |
60 |
$895.70 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
15 |
$678.70 |
| D7140 |
Extraction, erupted tooth or exposed root |
13 |
12 |
$586.80 |
| D0220 |
Intraoral - periapical first radiographic image |
29 |
28 |
$156.80 |