| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
214 |
209 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
230 |
227 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
67 |
52 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
95 |
57 |
$3K |
| D0274 |
Bitewings - four radiographic images |
115 |
115 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
66 |
63 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
37 |
27 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
251 |
245 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
50 |
48 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
226 |
217 |
$931.00 |
| D0272 |
Bitewings - two radiographic images |
73 |
69 |
$686.20 |
| D0140 |
Limited oral evaluation - problem focused |
37 |
34 |
$567.00 |
| D1110 |
Prophylaxis - adult |
14 |
14 |
$355.60 |