| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
655 |
654 |
$34K |
| D1110 |
Prophylaxis - adult |
210 |
210 |
$17K |
| D1120 |
Prophylaxis - child |
533 |
531 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
238 |
238 |
$15K |
| D0274 |
Bitewings - four radiographic images |
638 |
638 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,766 |
881 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
77 |
38 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
371 |
371 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
51 |
27 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
37 |
37 |
$2K |
| D1351 |
Sealant - per tooth |
80 |
18 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
108 |
108 |
$1K |
| D0272 |
Bitewings - two radiographic images |
50 |
50 |
$600.00 |