| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0220 |
Intraoral - periapical first radiographic image |
263 |
244 |
$3K |
| D1110 |
Prophylaxis - adult |
79 |
78 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
91 |
84 |
$3K |
| D1120 |
Prophylaxis - child |
64 |
64 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
89 |
89 |
$2K |
| D0274 |
Bitewings - four radiographic images |
84 |
77 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
12 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
20 |
16 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
67 |
67 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
188 |
135 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
39 |
32 |
$1K |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$288.00 |