| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
301 |
294 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
179 |
177 |
$10K |
| D1120 |
Prophylaxis - child |
255 |
252 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
174 |
171 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,470 |
324 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
343 |
339 |
$3K |
| D9430 |
|
118 |
101 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
36 |
12 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
20 |
13 |
$2K |
| D0274 |
Bitewings - four radiographic images |
62 |
58 |
$984.60 |
| D0272 |
Bitewings - two radiographic images |
69 |
69 |
$786.00 |
| D0220 |
Intraoral - periapical first radiographic image |
50 |
45 |
$455.50 |