| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
597 |
597 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
609 |
609 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
591 |
591 |
$16K |
| D0274 |
Bitewings - four radiographic images |
246 |
245 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
173 |
172 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
185 |
183 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
503 |
495 |
$3K |
| D1351 |
Sealant - per tooth |
25 |
12 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
33 |
24 |
$2K |
| D1110 |
Prophylaxis - adult |
41 |
41 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
407 |
400 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
13 |
13 |
$1K |
| D0272 |
Bitewings - two radiographic images |
89 |
89 |
$964.83 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
12 |
$873.60 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$384.11 |