| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
237 |
236 |
$4K |
| D1110 |
Prophylaxis - adult |
102 |
102 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
52 |
26 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
110 |
109 |
$3K |
| D1120 |
Prophylaxis - child |
114 |
114 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
49 |
36 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
132 |
132 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
33 |
25 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
58 |
58 |
$2K |
| D0274 |
Bitewings - four radiographic images |
77 |
77 |
$1K |
| D0330 |
Panoramic radiographic image |
18 |
18 |
$875.52 |
| D0220 |
Intraoral - periapical first radiographic image |
99 |
92 |
$467.25 |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$204.75 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$115.50 |