| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
704 |
700 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
848 |
846 |
$14K |
| D0330 |
Panoramic radiographic image |
247 |
247 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
517 |
516 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
133 |
75 |
$7K |
| D0274 |
Bitewings - four radiographic images |
353 |
352 |
$7K |
| D1120 |
Prophylaxis - child |
355 |
341 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
195 |
195 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
184 |
174 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
62 |
38 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
63 |
13 |
$3K |
| D2394 |
|
34 |
25 |
$3K |
| D0272 |
Bitewings - two radiographic images |
39 |
39 |
$380.00 |
| D0220 |
Intraoral - periapical first radiographic image |
59 |
55 |
$295.00 |