| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
712 |
660 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
859 |
811 |
$17K |
| D0274 |
Bitewings - four radiographic images |
441 |
402 |
$12K |
| D1206 |
Topical application of fluoride varnish |
697 |
660 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
410 |
381 |
$11K |
| D0330 |
Panoramic radiographic image |
187 |
174 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
278 |
240 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
63 |
14 |
$5K |
| D1120 |
Prophylaxis - child |
128 |
124 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
320 |
280 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
42 |
24 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
28 |
13 |
$2K |