| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
135 |
135 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
127 |
66 |
$8K |
| D1110 |
Prophylaxis - adult |
121 |
120 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
131 |
131 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
33 |
26 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
118 |
117 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
72 |
70 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
152 |
146 |
$2K |
| D1120 |
Prophylaxis - child |
46 |
46 |
$2K |
| D0274 |
Bitewings - four radiographic images |
48 |
47 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
118 |
78 |
$1K |
| D1206 |
Topical application of fluoride varnish |
58 |
58 |
$1K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$241.80 |