| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
100 |
91 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
100 |
90 |
$3K |
| D1206 |
Topical application of fluoride varnish |
88 |
79 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
22 |
18 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
14 |
$1K |
| D0274 |
Bitewings - four radiographic images |
52 |
45 |
$828.10 |
| D0220 |
Intraoral - periapical first radiographic image |
141 |
124 |
$756.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
12 |
$586.15 |
| D0230 |
Intraoral - periapical each additional radiographic image |
124 |
111 |
$509.20 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
23 |
21 |
$484.15 |
| D1110 |
Prophylaxis - adult |
19 |
16 |
$482.60 |
| D0272 |
Bitewings - two radiographic images |
42 |
38 |
$394.80 |
| D0140 |
Limited oral evaluation - problem focused |
22 |
18 |
$307.80 |