| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,331 |
1,331 |
$27K |
| D1110 |
Prophylaxis - adult |
589 |
589 |
$25K |
| D1206 |
Topical application of fluoride varnish |
1,574 |
1,574 |
$23K |
| D1120 |
Prophylaxis - child |
795 |
795 |
$23K |
| D0140 |
Limited oral evaluation - problem focused |
354 |
350 |
$10K |
| D0330 |
Panoramic radiographic image |
153 |
153 |
$7K |
| D0274 |
Bitewings - four radiographic images |
227 |
227 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
291 |
284 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
42 |
14 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
66 |
25 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
34 |
12 |
$4K |
| D0272 |
Bitewings - two radiographic images |
157 |
157 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
27 |
$746.01 |