| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
300 |
300 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
119 |
84 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
294 |
293 |
$8K |
| D0274 |
Bitewings - four radiographic images |
201 |
200 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
87 |
47 |
$5K |
| D0330 |
Panoramic radiographic image |
131 |
131 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
84 |
84 |
$2K |
| D1120 |
Prophylaxis - child |
30 |
30 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
51 |
50 |
$611.20 |
| D1208 |
Topical application of fluoride, excluding varnish |
29 |
29 |
$372.10 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$147.70 |