| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
658 |
657 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
629 |
628 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
334 |
100 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
267 |
111 |
$13K |
| D0274 |
Bitewings - four radiographic images |
430 |
430 |
$11K |
| D1351 |
Sealant - per tooth |
258 |
83 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
773 |
772 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
565 |
564 |
$7K |
| D1354 |
|
151 |
38 |
$6K |
| D1110 |
Prophylaxis - adult |
96 |
96 |
$4K |
| D1206 |
Topical application of fluoride varnish |
131 |
131 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
117 |
116 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
146 |
146 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
23 |
14 |
$1K |
| D0272 |
Bitewings - two radiographic images |
48 |
48 |
$686.75 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
13 |
$108.30 |