| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,100 |
1,098 |
$61K |
| D1110 |
Prophylaxis - adult |
624 |
624 |
$54K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
592 |
589 |
$35K |
| D9430 |
|
1,004 |
877 |
$31K |
| D1120 |
Prophylaxis - child |
555 |
553 |
$19K |
| D0274 |
Bitewings - four radiographic images |
813 |
813 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,377 |
1,376 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,612 |
1,532 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
267 |
266 |
$12K |
| D0330 |
Panoramic radiographic image |
288 |
288 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
571 |
543 |
$7K |
| D4910 |
|
78 |
76 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
45 |
12 |
$5K |
| D0350 |
|
364 |
133 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
40 |
12 |
$3K |
| D1206 |
Topical application of fluoride varnish |
84 |
83 |
$706.00 |