| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
179 |
164 |
$10K |
| D0330 |
Panoramic radiographic image |
99 |
76 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
217 |
177 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
133 |
106 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
68 |
42 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
78 |
31 |
$5K |
| D0274 |
Bitewings - four radiographic images |
97 |
68 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
65 |
26 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
53 |
43 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
189 |
158 |
$2K |
| D1120 |
Prophylaxis - child |
43 |
32 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
60 |
52 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
72 |
60 |
$880.04 |