| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
575 |
564 |
$35K |
| D1110 |
Prophylaxis - adult |
353 |
350 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
524 |
516 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
181 |
93 |
$14K |
| D0274 |
Bitewings - four radiographic images |
428 |
421 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
272 |
262 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
196 |
118 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
194 |
115 |
$10K |
| D1120 |
Prophylaxis - child |
131 |
130 |
$7K |
| D1206 |
Topical application of fluoride varnish |
249 |
247 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
78 |
78 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
178 |
167 |
$2K |