| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
938 |
938 |
$46K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
478 |
478 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
727 |
727 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,189 |
1,134 |
$15K |
| D0274 |
Bitewings - four radiographic images |
499 |
499 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
99 |
59 |
$9K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
53 |
26 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
181 |
176 |
$6K |
| D0330 |
Panoramic radiographic image |
112 |
112 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
209 |
198 |
$2K |
| D1120 |
Prophylaxis - child |
53 |
53 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
24 |
24 |
$388.80 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$210.60 |