| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,377 |
2,376 |
$70K |
| D1110 |
Prophylaxis - adult |
1,200 |
1,199 |
$59K |
| D1120 |
Prophylaxis - child |
492 |
492 |
$23K |
| D1206 |
Topical application of fluoride varnish |
419 |
419 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
151 |
63 |
$9K |
| D0274 |
Bitewings - four radiographic images |
503 |
502 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
199 |
199 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
76 |
55 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
659 |
647 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
57 |
43 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
33 |
33 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$621.00 |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$287.50 |
| D0601 |
|
13 |
13 |
$100.00 |