| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
454 |
400 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
77 |
56 |
$5K |
| D1120 |
Prophylaxis - child |
97 |
91 |
$4K |
| D0274 |
Bitewings - four radiographic images |
177 |
164 |
$2K |
| D0330 |
Panoramic radiographic image |
138 |
133 |
$2K |
| D0272 |
Bitewings - two radiographic images |
83 |
71 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
293 |
272 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
13 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
28 |
28 |
$728.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
236 |
221 |
$638.40 |
| D1110 |
Prophylaxis - adult |
26 |
26 |
$533.00 |
| D0210 |
Intraoral - complete series of radiographic images |
17 |
17 |
$414.00 |