| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
822 |
816 |
$38K |
| D0210 |
Intraoral - complete series of radiographic images |
384 |
383 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
725 |
720 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
430 |
430 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
222 |
222 |
$10K |
| D1120 |
Prophylaxis - child |
86 |
86 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
665 |
655 |
$4K |
| D0274 |
Bitewings - four radiographic images |
195 |
195 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
12 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
66 |
66 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
19 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
204 |
203 |
$883.50 |