| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
323 |
323 |
$13K |
| D1110 |
Prophylaxis - adult |
262 |
256 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
359 |
357 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
315 |
315 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
307 |
300 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
109 |
94 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
195 |
187 |
$4K |
| D0274 |
Bitewings - four radiographic images |
156 |
155 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
45 |
41 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
141 |
133 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
163 |
156 |
$851.20 |
| D0272 |
Bitewings - two radiographic images |
55 |
55 |
$498.20 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$57.00 |