| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
436 |
430 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
427 |
417 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
172 |
114 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
334 |
328 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
109 |
62 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
173 |
170 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
59 |
40 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
449 |
428 |
$2K |
| D1206 |
Topical application of fluoride varnish |
67 |
67 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
502 |
478 |
$2K |
| D0274 |
Bitewings - four radiographic images |
99 |
96 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
61 |
58 |
$1K |
| D0272 |
Bitewings - two radiographic images |
69 |
69 |
$647.55 |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$628.94 |