| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
443 |
423 |
$20K |
| D1110 |
Prophylaxis - adult |
484 |
468 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
673 |
646 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
182 |
87 |
$10K |
| D0330 |
Panoramic radiographic image |
264 |
257 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
368 |
356 |
$9K |
| D0274 |
Bitewings - four radiographic images |
354 |
340 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
131 |
70 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
324 |
302 |
$5K |
| D1206 |
Topical application of fluoride varnish |
343 |
337 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
152 |
142 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
237 |
217 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
44 |
43 |
$812.77 |
| D7140 |
Extraction, erupted tooth or exposed root |
12 |
12 |
$478.80 |