| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,316 |
2,316 |
$128K |
| D0120 |
Periodic oral evaluation - established patient |
2,399 |
2,399 |
$68K |
| D0274 |
Bitewings - four radiographic images |
1,114 |
1,114 |
$28K |
| D0330 |
Panoramic radiographic image |
590 |
590 |
$22K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
144 |
80 |
$12K |
| D2394 |
|
57 |
39 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
65 |
38 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
514 |
513 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
139 |
139 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
94 |
94 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
30 |
30 |
$961.00 |