| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
279 |
275 |
$12K |
| D0330 |
Panoramic radiographic image |
261 |
166 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
93 |
50 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
352 |
220 |
$7K |
| D0274 |
Bitewings - four radiographic images |
230 |
227 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
57 |
20 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
197 |
195 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
399 |
241 |
$3K |
| D1120 |
Prophylaxis - child |
72 |
72 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
354 |
158 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
159 |
95 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
81 |
81 |
$2K |