| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
387 |
362 |
$15K |
| D1351 |
Sealant - per tooth |
257 |
116 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
396 |
375 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
261 |
245 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
110 |
89 |
$6K |
| D1206 |
Topical application of fluoride varnish |
104 |
95 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
104 |
95 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
38 |
28 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
284 |
270 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
105 |
95 |
$1K |
| D0274 |
Bitewings - four radiographic images |
89 |
86 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
230 |
217 |
$874.00 |
| D0272 |
Bitewings - two radiographic images |
94 |
87 |
$817.80 |
| D0210 |
Intraoral - complete series of radiographic images |
19 |
16 |
$476.00 |
| D1110 |
Prophylaxis - adult |
14 |
14 |
$330.20 |