| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
398 |
396 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
365 |
350 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
351 |
348 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
139 |
82 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
238 |
238 |
$6K |
| D1120 |
Prophylaxis - child |
141 |
141 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
534 |
529 |
$4K |
| D0274 |
Bitewings - four radiographic images |
183 |
183 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
53 |
37 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
45 |
27 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
61 |
60 |
$630.00 |
| D0350 |
|
120 |
75 |
$600.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
50 |
43 |
$141.00 |