| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
590 |
590 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
542 |
542 |
$12K |
| D0274 |
Bitewings - four radiographic images |
374 |
374 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
660 |
660 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
142 |
96 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
169 |
119 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
581 |
580 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
120 |
120 |
$3K |
| D1351 |
Sealant - per tooth |
59 |
18 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
25 |
21 |
$1K |
| D1110 |
Prophylaxis - adult |
16 |
16 |
$698.60 |
| D0230 |
Intraoral - periapical each additional radiographic image |
73 |
73 |
$514.80 |
| D0140 |
Limited oral evaluation - problem focused |
38 |
37 |
$382.55 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$182.65 |