| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
619 |
606 |
$24K |
| D1120 |
Prophylaxis - child |
578 |
577 |
$23K |
| D1206 |
Topical application of fluoride varnish |
875 |
875 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
234 |
93 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
179 |
172 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
440 |
436 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
151 |
142 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
27 |
12 |
$2K |
| D1110 |
Prophylaxis - adult |
30 |
29 |
$1K |
| D0274 |
Bitewings - four radiographic images |
39 |
39 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
56 |
28 |
$482.85 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$274.00 |