| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
238 |
227 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
311 |
294 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
213 |
202 |
$5K |
| D0274 |
Bitewings - four radiographic images |
201 |
193 |
$3K |
| D1351 |
Sealant - per tooth |
24 |
17 |
$2K |
| D1110 |
Prophylaxis - adult |
48 |
48 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
37 |
31 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
70 |
68 |
$1K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
15 |
13 |
$975.80 |
| D0220 |
Intraoral - periapical first radiographic image |
158 |
151 |
$873.60 |
| D9110 |
|
12 |
12 |
$660.00 |
| D0330 |
Panoramic radiographic image |
29 |
24 |
$610.20 |
| D0272 |
Bitewings - two radiographic images |
59 |
54 |
$554.60 |
| D0230 |
Intraoral - periapical each additional radiographic image |
72 |
69 |
$505.40 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
12 |
12 |
$462.75 |
| D1999 |
|
207 |
185 |
$0.00 |