| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
549 |
542 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
545 |
545 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
632 |
632 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
156 |
69 |
$8K |
| D1110 |
Prophylaxis - adult |
231 |
231 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
109 |
12 |
$6K |
| D1120 |
Prophylaxis - child |
262 |
261 |
$5K |
| D1206 |
Topical application of fluoride varnish |
234 |
234 |
$3K |
| D0350 |
|
194 |
193 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
36 |
13 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
46 |
26 |
$2K |
| D0274 |
Bitewings - four radiographic images |
109 |
109 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
126 |
126 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
182 |
181 |
$895.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
123 |
64 |
$585.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$248.38 |