| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
356 |
356 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
388 |
388 |
$11K |
| D1206 |
Topical application of fluoride varnish |
245 |
245 |
$7K |
| D1110 |
Prophylaxis - adult |
100 |
100 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
153 |
153 |
$4K |
| D0274 |
Bitewings - four radiographic images |
173 |
173 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
55 |
36 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
395 |
392 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
132 |
129 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
290 |
290 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
65 |
65 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
27 |
17 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
44 |
44 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
14 |
$764.40 |
| D0272 |
Bitewings - two radiographic images |
34 |
34 |
$377.06 |