| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
855 |
855 |
$36K |
| D1208 |
Topical application of fluoride, excluding varnish |
799 |
799 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
577 |
577 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
201 |
138 |
$13K |
| D1351 |
Sealant - per tooth |
219 |
91 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,120 |
1,100 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
266 |
266 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
958 |
951 |
$7K |
| D0274 |
Bitewings - four radiographic images |
329 |
329 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
146 |
120 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
51 |
37 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
199 |
198 |
$4K |
| D0272 |
Bitewings - two radiographic images |
212 |
212 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
17 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
34 |
26 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$370.69 |
| D0270 |
|
12 |
12 |
$67.20 |