| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
105 |
105 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
77 |
48 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
80 |
68 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
66 |
65 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
126 |
126 |
$7K |
| D1110 |
Prophylaxis - adult |
98 |
93 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
144 |
134 |
$5K |
| D1120 |
Prophylaxis - child |
92 |
86 |
$3K |
| D1206 |
Topical application of fluoride varnish |
111 |
104 |
$3K |
| D0274 |
Bitewings - four radiographic images |
79 |
75 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
43 |
41 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
35 |
34 |
$350.88 |