| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
561 |
429 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
573 |
433 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
560 |
428 |
$11K |
| D0274 |
Bitewings - four radiographic images |
268 |
218 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
116 |
45 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
61 |
32 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
129 |
108 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
511 |
405 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
419 |
329 |
$2K |
| D1110 |
Prophylaxis - adult |
51 |
42 |
$2K |
| D1351 |
Sealant - per tooth |
39 |
15 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
108 |
78 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
16 |
$1K |
| D0272 |
Bitewings - two radiographic images |
60 |
43 |
$376.00 |