| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,854 |
1,854 |
$91K |
| D0120 |
Periodic oral evaluation - established patient |
1,785 |
1,785 |
$39K |
| D0140 |
Limited oral evaluation - problem focused |
799 |
793 |
$29K |
| D0274 |
Bitewings - four radiographic images |
1,140 |
1,140 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,629 |
1,629 |
$26K |
| D0330 |
Panoramic radiographic image |
508 |
508 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
341 |
341 |
$14K |
| D1120 |
Prophylaxis - child |
356 |
356 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
63 |
36 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
278 |
275 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
30 |
13 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
15 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
65 |
65 |
$1K |
| D1206 |
Topical application of fluoride varnish |
59 |
59 |
$973.50 |