| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,239 |
1,229 |
$40K |
| D1110 |
Prophylaxis - adult |
631 |
631 |
$35K |
| D1206 |
Topical application of fluoride varnish |
1,351 |
1,341 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
292 |
170 |
$31K |
| D1120 |
Prophylaxis - child |
729 |
724 |
$30K |
| D0274 |
Bitewings - four radiographic images |
510 |
510 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
230 |
157 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
100 |
100 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
253 |
249 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
86 |
86 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
20 |
12 |
$3K |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$984.50 |
| D0272 |
Bitewings - two radiographic images |
26 |
26 |
$741.02 |