| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
467 |
467 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
594 |
593 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
417 |
417 |
$11K |
| D0274 |
Bitewings - four radiographic images |
470 |
469 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
213 |
213 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
82 |
63 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
563 |
560 |
$4K |
| D4341 |
|
21 |
12 |
$3K |
| D1110 |
Prophylaxis - adult |
71 |
71 |
$3K |
| D1351 |
Sealant - per tooth |
59 |
27 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
469 |
387 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
99 |
98 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
16 |
12 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
14 |
$764.40 |
| D0272 |
Bitewings - two radiographic images |
54 |
54 |
$587.77 |
| D0210 |
Intraoral - complete series of radiographic images |
16 |
16 |
$237.09 |