| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
666 |
663 |
$44K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
375 |
370 |
$21K |
| D1206 |
Topical application of fluoride varnish |
656 |
655 |
$17K |
| D0330 |
Panoramic radiographic image |
269 |
267 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
364 |
364 |
$12K |
| D0274 |
Bitewings - four radiographic images |
351 |
351 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
57 |
28 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
50 |
26 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
79 |
77 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
225 |
224 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
125 |
125 |
$833.12 |