| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
615 |
615 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
785 |
784 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
168 |
152 |
$10K |
| D0274 |
Bitewings - four radiographic images |
295 |
294 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
138 |
104 |
$7K |
| D1120 |
Prophylaxis - child |
219 |
219 |
$7K |
| D0330 |
Panoramic radiographic image |
148 |
147 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
244 |
244 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
61 |
42 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
128 |
127 |
$3K |
| D1206 |
Topical application of fluoride varnish |
24 |
24 |
$432.00 |
| D0220 |
Intraoral - periapical first radiographic image |
19 |
19 |
$152.00 |