| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
774 |
774 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
1,027 |
1,027 |
$23K |
| D1206 |
Topical application of fluoride varnish |
950 |
928 |
$21K |
| D1120 |
Prophylaxis - child |
365 |
365 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
92 |
56 |
$7K |
| D0274 |
Bitewings - four radiographic images |
425 |
425 |
$5K |
| D1999 |
|
507 |
449 |
$5K |
| D1351 |
Sealant - per tooth |
215 |
42 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
154 |
154 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
26 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
75 |
75 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
30 |
30 |
$1K |
| D0330 |
Panoramic radiographic image |
158 |
158 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
163 |
158 |
$856.29 |
| D0272 |
Bitewings - two radiographic images |
68 |
68 |
$669.86 |