| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
350 |
337 |
$13K |
| D4341 |
|
92 |
43 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
187 |
129 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
329 |
323 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
338 |
325 |
$8K |
| D1110 |
Prophylaxis - adult |
185 |
184 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
152 |
94 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
356 |
345 |
$7K |
| D1351 |
Sealant - per tooth |
149 |
46 |
$6K |
| D0274 |
Bitewings - four radiographic images |
370 |
362 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
96 |
77 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
632 |
498 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
539 |
528 |
$3K |
| D0272 |
Bitewings - two radiographic images |
90 |
90 |
$817.80 |
| D0140 |
Limited oral evaluation - problem focused |
31 |
31 |
$469.80 |
| D0210 |
Intraoral - complete series of radiographic images |
68 |
67 |
$447.20 |