| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,371 |
1,371 |
$20K |
| D1120 |
Prophylaxis - child |
1,404 |
1,404 |
$19K |
| D1206 |
Topical application of fluoride varnish |
1,042 |
1,042 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
379 |
238 |
$6K |
| D0272 |
Bitewings - two radiographic images |
673 |
673 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
673 |
668 |
$2K |
| D1351 |
Sealant - per tooth |
626 |
115 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
538 |
538 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
127 |
97 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
45 |
37 |
$525.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
63 |
63 |
$468.00 |
| D0274 |
Bitewings - four radiographic images |
120 |
120 |
$423.00 |
| D0140 |
Limited oral evaluation - problem focused |
38 |
38 |
$365.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
496 |
496 |
$152.00 |
| D0603 |
|
13 |
13 |
$60.00 |
| D0601 |
|
12 |
12 |
$50.00 |