| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
448 |
448 |
$15K |
| D1206 |
Topical application of fluoride varnish |
592 |
592 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
127 |
69 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
517 |
517 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
102 |
43 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
203 |
203 |
$6K |
| D1110 |
Prophylaxis - adult |
102 |
102 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
297 |
288 |
$3K |
| D0274 |
Bitewings - four radiographic images |
84 |
84 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
77 |
77 |
$2K |
| D0272 |
Bitewings - two radiographic images |
69 |
69 |
$1K |
| D9630 |
|
43 |
42 |
$854.41 |
| D0210 |
Intraoral - complete series of radiographic images |
19 |
18 |
$776.73 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$647.88 |
| D0230 |
Intraoral - periapical each additional radiographic image |
25 |
16 |
$279.50 |