| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
697 |
673 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
287 |
192 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
588 |
569 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
469 |
452 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
458 |
443 |
$9K |
| D1351 |
Sealant - per tooth |
117 |
60 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
746 |
645 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
704 |
675 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
128 |
126 |
$4K |
| D0272 |
Bitewings - two radiographic images |
230 |
223 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
39 |
27 |
$2K |
| D0274 |
Bitewings - four radiographic images |
87 |
86 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
12 |
$832.95 |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$330.20 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$194.40 |