| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0230 |
Intraoral - periapical each additional radiographic image |
1,191 |
251 |
$4K |
| D0274 |
Bitewings - four radiographic images |
192 |
190 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
103 |
102 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
187 |
186 |
$3K |
| D1120 |
Prophylaxis - child |
79 |
79 |
$2K |
| D1110 |
Prophylaxis - adult |
59 |
59 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
12 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
27 |
27 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
21 |
14 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
80 |
77 |
$775.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
74 |
74 |
$619.50 |