| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
214 |
210 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
292 |
287 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
54 |
27 |
$5K |
| D1120 |
Prophylaxis - child |
198 |
194 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
118 |
117 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
270 |
266 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
33 |
12 |
$3K |
| D0274 |
Bitewings - four radiographic images |
84 |
84 |
$2K |
| D0330 |
Panoramic radiographic image |
45 |
44 |
$2K |
| D0272 |
Bitewings - two radiographic images |
31 |
31 |
$527.70 |
| D0220 |
Intraoral - periapical first radiographic image |
34 |
31 |
$441.76 |
| D0230 |
Intraoral - periapical each additional radiographic image |
22 |
12 |
$294.31 |