| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
231 |
207 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
214 |
194 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
163 |
135 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
70 |
40 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
156 |
136 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
57 |
33 |
$3K |
| D1351 |
Sealant - per tooth |
40 |
18 |
$2K |
| D0274 |
Bitewings - four radiographic images |
157 |
143 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
60 |
32 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
326 |
288 |
$2K |
| D1110 |
Prophylaxis - adult |
36 |
24 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
215 |
190 |
$836.00 |
| D0140 |
Limited oral evaluation - problem focused |
54 |
37 |
$810.00 |
| D0210 |
Intraoral - complete series of radiographic images |
32 |
21 |
$803.30 |
| D0272 |
Bitewings - two radiographic images |
53 |
47 |
$470.00 |