| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
711 |
711 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,118 |
1,112 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
161 |
79 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
320 |
320 |
$11K |
| D0330 |
Panoramic radiographic image |
207 |
207 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
81 |
50 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
140 |
140 |
$5K |
| D0274 |
Bitewings - four radiographic images |
199 |
199 |
$5K |
| D1110 |
Prophylaxis - adult |
54 |
54 |
$3K |
| D1206 |
Topical application of fluoride varnish |
116 |
116 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
31 |
29 |
$313.08 |