| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
682 |
682 |
$19K |
| D1120 |
Prophylaxis - child |
422 |
422 |
$18K |
| D1110 |
Prophylaxis - adult |
275 |
275 |
$13K |
| D4341 |
|
85 |
40 |
$12K |
| D1206 |
Topical application of fluoride varnish |
402 |
402 |
$11K |
| D0274 |
Bitewings - four radiographic images |
489 |
489 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
227 |
227 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
875 |
875 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
801 |
801 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
45 |
29 |
$3K |
| D0330 |
Panoramic radiographic image |
83 |
83 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
51 |
41 |
$2K |
| D0272 |
Bitewings - two radiographic images |
143 |
143 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
82 |
82 |
$2K |
| D0270 |
|
18 |
18 |
$95.20 |