| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
490 |
489 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
110 |
40 |
$8K |
| D1351 |
Sealant - per tooth |
141 |
44 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
140 |
30 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
452 |
449 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
207 |
207 |
$5K |
| D1206 |
Topical application of fluoride varnish |
196 |
194 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
66 |
39 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
137 |
136 |
$3K |
| D0272 |
Bitewings - two radiographic images |
165 |
164 |
$2K |
| D0274 |
Bitewings - four radiographic images |
85 |
85 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
177 |
177 |
$2K |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$648.70 |
| D0230 |
Intraoral - periapical each additional radiographic image |
74 |
74 |
$445.85 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$156.10 |
| D1310 |
|
104 |
104 |
$0.00 |
| D1330 |
|
93 |
93 |
$0.00 |