| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
766 |
766 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
560 |
560 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
172 |
125 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
592 |
592 |
$8K |
| D1351 |
Sealant - per tooth |
177 |
62 |
$8K |
| D0272 |
Bitewings - two radiographic images |
455 |
455 |
$8K |
| D1206 |
Topical application of fluoride varnish |
212 |
212 |
$7K |
| D0240 |
|
408 |
400 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
143 |
104 |
$6K |
| D1354 |
|
111 |
31 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
121 |
121 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
371 |
370 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
87 |
87 |
$3K |
| D0330 |
Panoramic radiographic image |
43 |
43 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
124 |
122 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
14 |
14 |
$798.00 |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$716.30 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
15 |
$196.65 |
| D1999 |
|
25 |
25 |
$0.00 |