| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
535 |
494 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
356 |
228 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
670 |
608 |
$14K |
| D1206 |
Topical application of fluoride varnish |
576 |
543 |
$12K |
| D0330 |
Panoramic radiographic image |
246 |
245 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
330 |
311 |
$8K |
| D0274 |
Bitewings - four radiographic images |
315 |
290 |
$6K |
| D1110 |
Prophylaxis - adult |
148 |
144 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
88 |
70 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
113 |
78 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
129 |
86 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
167 |
149 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
97 |
96 |
$3K |
| D0272 |
Bitewings - two radiographic images |
106 |
103 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
161 |
153 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
18 |
16 |
$404.85 |
| D0230 |
Intraoral - periapical each additional radiographic image |
49 |
29 |
$260.43 |