| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,625 |
1,625 |
$70K |
| D0120 |
Periodic oral evaluation - established patient |
3,414 |
3,414 |
$67K |
| D1120 |
Prophylaxis - child |
1,787 |
1,787 |
$49K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,608 |
2,608 |
$36K |
| D0274 |
Bitewings - four radiographic images |
634 |
634 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
111 |
57 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
31 |
13 |
$4K |
| D0330 |
Panoramic radiographic image |
71 |
71 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
24 |
12 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
38 |
38 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
36 |
35 |
$1K |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$237.90 |