| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,625 |
1,624 |
$88K |
| D0120 |
Periodic oral evaluation - established patient |
1,263 |
1,263 |
$34K |
| D0274 |
Bitewings - four radiographic images |
808 |
808 |
$18K |
| D0330 |
Panoramic radiographic image |
281 |
281 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
248 |
247 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
42 |
25 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
13 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
54 |
53 |
$702.40 |
| D0220 |
Intraoral - periapical first radiographic image |
27 |
26 |
$303.94 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$302.40 |
| D1208 |
Topical application of fluoride, excluding varnish |
25 |
25 |
$107.10 |