| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,175 |
1,175 |
$58K |
| D0120 |
Periodic oral evaluation - established patient |
1,512 |
1,512 |
$34K |
| D1206 |
Topical application of fluoride varnish |
988 |
988 |
$16K |
| D0330 |
Panoramic radiographic image |
322 |
322 |
$15K |
| D1120 |
Prophylaxis - child |
362 |
362 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
59 |
41 |
$6K |
| D0274 |
Bitewings - four radiographic images |
195 |
195 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
33 |
20 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
19 |
12 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
25 |
25 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
27 |
27 |
$991.90 |
| D0220 |
Intraoral - periapical first radiographic image |
27 |
27 |
$312.41 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$236.82 |