| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
553 |
553 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
1,040 |
1,040 |
$28K |
| D1120 |
Prophylaxis - child |
498 |
498 |
$19K |
| D0274 |
Bitewings - four radiographic images |
297 |
297 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
419 |
419 |
$6K |
| D1206 |
Topical application of fluoride varnish |
205 |
205 |
$6K |
| D9310 |
|
42 |
42 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
12 |
12 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
14 |
12 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
47 |
47 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$388.00 |
| D0140 |
Limited oral evaluation - problem focused |
27 |
27 |
$355.88 |
| D0220 |
Intraoral - periapical first radiographic image |
24 |
24 |
$326.62 |