| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
363 |
363 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
444 |
444 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
82 |
57 |
$11K |
| D1110 |
Prophylaxis - adult |
178 |
178 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
78 |
59 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
365 |
365 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
221 |
221 |
$5K |
| D0274 |
Bitewings - four radiographic images |
136 |
136 |
$5K |
| D1206 |
Topical application of fluoride varnish |
158 |
158 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
305 |
297 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
53 |
53 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
19 |
13 |
$2K |
| D1351 |
Sealant - per tooth |
47 |
13 |
$1K |
| D0330 |
Panoramic radiographic image |
24 |
24 |
$1K |
| D0272 |
Bitewings - two radiographic images |
41 |
41 |
$960.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$516.00 |