| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
388 |
387 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
402 |
399 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
357 |
356 |
$9K |
| D1110 |
Prophylaxis - adult |
206 |
202 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
241 |
240 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
55 |
41 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
108 |
106 |
$3K |
| D0274 |
Bitewings - four radiographic images |
161 |
160 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
162 |
160 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
44 |
27 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
19 |
$740.40 |
| D0272 |
Bitewings - two radiographic images |
62 |
62 |
$582.80 |
| D0220 |
Intraoral - periapical first radiographic image |
103 |
103 |
$571.20 |
| D0270 |
|
13 |
13 |
$72.80 |