| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
224 |
224 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
309 |
309 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
308 |
301 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
614 |
316 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
73 |
30 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
177 |
177 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
409 |
393 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
17 |
12 |
$2K |
| D1351 |
Sealant - per tooth |
47 |
13 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
12 |
$1K |
| D1110 |
Prophylaxis - adult |
29 |
29 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
44 |
42 |
$968.37 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$358.80 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$241.80 |