| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
388 |
332 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
469 |
415 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
363 |
309 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
248 |
217 |
$7K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
72 |
40 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
76 |
65 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
650 |
546 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
106 |
95 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
552 |
413 |
$3K |
| D0274 |
Bitewings - four radiographic images |
175 |
145 |
$3K |
| D9110 |
|
31 |
26 |
$2K |
| D1110 |
Prophylaxis - adult |
14 |
13 |
$574.00 |
| D0140 |
Limited oral evaluation - problem focused |
19 |
19 |
$307.80 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$112.80 |