| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
480 |
471 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
623 |
603 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
193 |
183 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
420 |
399 |
$4K |
| D1206 |
Topical application of fluoride varnish |
241 |
237 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
185 |
175 |
$3K |
| D0274 |
Bitewings - four radiographic images |
117 |
113 |
$3K |
| D1110 |
Prophylaxis - adult |
62 |
62 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
40 |
25 |
$3K |
| D1351 |
Sealant - per tooth |
87 |
24 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
20 |
12 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
30 |
25 |
$720.06 |
| D0272 |
Bitewings - two radiographic images |
27 |
27 |
$540.60 |
| D0230 |
Intraoral - periapical each additional radiographic image |
14 |
14 |
$143.32 |