| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
442 |
442 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
532 |
532 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
427 |
427 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
187 |
148 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
231 |
159 |
$11K |
| D1351 |
Sealant - per tooth |
144 |
51 |
$9K |
| D0274 |
Bitewings - four radiographic images |
365 |
365 |
$7K |
| D1110 |
Prophylaxis - adult |
131 |
131 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
95 |
68 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
160 |
160 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
618 |
443 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
517 |
514 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
68 |
68 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
53 |
51 |
$1K |
| D0272 |
Bitewings - two radiographic images |
45 |
45 |
$499.05 |