| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
958 |
954 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
985 |
981 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,119 |
1,113 |
$8K |
| D0272 |
Bitewings - two radiographic images |
759 |
757 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
298 |
297 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
908 |
908 |
$4K |
| D1120 |
Prophylaxis - child |
80 |
80 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
38 |
24 |
$1K |
| D0330 |
Panoramic radiographic image |
84 |
84 |
$823.10 |
| D0210 |
Intraoral - complete series of radiographic images |
75 |
74 |
$793.54 |
| D1208 |
Topical application of fluoride, excluding varnish |
62 |
62 |
$451.06 |
| D7140 |
Extraction, erupted tooth or exposed root |
12 |
12 |
$444.12 |