| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,661 |
1,660 |
$96K |
| D0120 |
Periodic oral evaluation - established patient |
1,685 |
1,685 |
$48K |
| D2394 |
|
239 |
172 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
347 |
234 |
$33K |
| D0330 |
Panoramic radiographic image |
491 |
491 |
$18K |
| D0274 |
Bitewings - four radiographic images |
363 |
363 |
$11K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
57 |
56 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
193 |
193 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
321 |
320 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
279 |
275 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
173 |
173 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
86 |
86 |
$1K |
| D1120 |
Prophylaxis - child |
12 |
12 |
$675.96 |