| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
462 |
462 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
371 |
371 |
$11K |
| D1206 |
Topical application of fluoride varnish |
238 |
238 |
$7K |
| D0272 |
Bitewings - two radiographic images |
256 |
256 |
$5K |
| D1351 |
Sealant - per tooth |
93 |
32 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
244 |
244 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
35 |
22 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
80 |
80 |
$2K |
| D1110 |
Prophylaxis - adult |
33 |
33 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
15 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
98 |
98 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
13 |
$836.76 |
| D0240 |
|
43 |
28 |
$705.06 |
| D0230 |
Intraoral - periapical each additional radiographic image |
42 |
42 |
$388.06 |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$290.21 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$175.11 |
| D0270 |
|
12 |
12 |
$149.17 |