| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
621 |
621 |
$25K |
| D1206 |
Topical application of fluoride varnish |
622 |
622 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
525 |
525 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
220 |
144 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
242 |
184 |
$8K |
| D0274 |
Bitewings - four radiographic images |
431 |
431 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
332 |
332 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
329 |
328 |
$2K |
| D1110 |
Prophylaxis - adult |
55 |
55 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
291 |
282 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
74 |
73 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
23 |
14 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
109 |
108 |
$1K |
| D0272 |
Bitewings - two radiographic images |
64 |
64 |
$582.80 |
| D0330 |
Panoramic radiographic image |
30 |
30 |
$519.80 |