| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
652 |
649 |
$43K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
278 |
144 |
$37K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
618 |
614 |
$35K |
| D0210 |
Intraoral - complete series of radiographic images |
526 |
524 |
$30K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
164 |
87 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
314 |
308 |
$15K |
| D1206 |
Topical application of fluoride varnish |
531 |
528 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
360 |
360 |
$11K |
| D1120 |
Prophylaxis - child |
86 |
86 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
309 |
290 |
$3K |
| D1330 |
|
109 |
109 |
$747.60 |
| D0274 |
Bitewings - four radiographic images |
30 |
30 |
$722.10 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$98.40 |