| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
294 |
290 |
$8K |
| D1120 |
Prophylaxis - child |
191 |
191 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
108 |
107 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
159 |
159 |
$6K |
| D1110 |
Prophylaxis - adult |
113 |
112 |
$6K |
| D1206 |
Topical application of fluoride varnish |
207 |
207 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
237 |
232 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
97 |
94 |
$3K |
| D4355 |
|
34 |
33 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
214 |
161 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
14 |
$1K |
| D0274 |
Bitewings - four radiographic images |
27 |
27 |
$884.00 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
19 |
12 |
$866.00 |