| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
850 |
849 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
1,023 |
1,022 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
301 |
239 |
$18K |
| D0274 |
Bitewings - four radiographic images |
588 |
588 |
$16K |
| D7140 |
Extraction, erupted tooth or exposed root |
230 |
139 |
$15K |
| D0330 |
Panoramic radiographic image |
321 |
321 |
$12K |
| D1120 |
Prophylaxis - child |
367 |
367 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
200 |
169 |
$10K |
| D1351 |
Sealant - per tooth |
287 |
55 |
$6K |
| D1206 |
Topical application of fluoride varnish |
280 |
279 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
224 |
224 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
244 |
244 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
65 |
60 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
211 |
210 |
$2K |
| D0272 |
Bitewings - two radiographic images |
24 |
24 |
$384.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
17 |
17 |
$340.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
13 |
$112.00 |
| D1330 |
|
12 |
12 |
$60.00 |