| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
467 |
459 |
$35K |
| D1351 |
Sealant - per tooth |
125 |
47 |
$3K |
| D1120 |
Prophylaxis - child |
333 |
326 |
$2K |
| D0330 |
Panoramic radiographic image |
105 |
101 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
15 |
$983.02 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$921.16 |
| D0340 |
|
32 |
32 |
$858.92 |
| D7140 |
Extraction, erupted tooth or exposed root |
22 |
18 |
$844.22 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
13 |
$767.00 |
| D0272 |
Bitewings - two radiographic images |
289 |
283 |
$356.43 |
| D0140 |
Limited oral evaluation - problem focused |
16 |
16 |
$280.11 |
| D0220 |
Intraoral - periapical first radiographic image |
343 |
337 |
$261.25 |
| D0240 |
|
78 |
76 |
$218.15 |
| D0274 |
Bitewings - four radiographic images |
105 |
105 |
$109.74 |
| D1330 |
|
517 |
509 |
$94.74 |
| D1206 |
Topical application of fluoride varnish |
442 |
435 |
$42.70 |
| D0230 |
Intraoral - periapical each additional radiographic image |
334 |
327 |
$40.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
63 |
62 |
$0.00 |
| D1110 |
Prophylaxis - adult |
142 |
141 |
$0.00 |