| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
178 |
167 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
39 |
16 |
$3K |
| D0330 |
Panoramic radiographic image |
50 |
46 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
44 |
43 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
56 |
48 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
16 |
13 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
84 |
73 |
$1K |
| D0274 |
Bitewings - four radiographic images |
46 |
42 |
$1K |
| D4355 |
|
22 |
17 |
$1K |
| D1110 |
Prophylaxis - adult |
30 |
26 |
$938.46 |
| D0220 |
Intraoral - periapical first radiographic image |
70 |
65 |
$891.70 |
| D0230 |
Intraoral - periapical each additional radiographic image |
43 |
36 |
$417.28 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$258.70 |