| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
543 |
543 |
$28K |
| D0330 |
Panoramic radiographic image |
575 |
575 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
379 |
225 |
$19K |
| D7140 |
Extraction, erupted tooth or exposed root |
368 |
120 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
590 |
590 |
$16K |
| D0274 |
Bitewings - four radiographic images |
504 |
502 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
136 |
99 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
345 |
345 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
506 |
490 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
323 |
321 |
$5K |
| D1120 |
Prophylaxis - child |
116 |
116 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
24 |
14 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
140 |
140 |
$2K |
| D2330 |
|
28 |
12 |
$2K |
| D4910 |
|
14 |
14 |
$663.00 |