| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,452 |
1,440 |
$40K |
| D1110 |
Prophylaxis - adult |
613 |
608 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
586 |
585 |
$29K |
| D1120 |
Prophylaxis - child |
1,091 |
1,082 |
$26K |
| D1206 |
Topical application of fluoride varnish |
940 |
932 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
195 |
100 |
$10K |
| D0274 |
Bitewings - four radiographic images |
533 |
532 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
160 |
102 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
135 |
135 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
56 |
25 |
$6K |
| D0330 |
Panoramic radiographic image |
232 |
232 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
804 |
490 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
237 |
236 |
$2K |
| D0272 |
Bitewings - two radiographic images |
95 |
95 |
$682.00 |