| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
569 |
565 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
953 |
945 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
197 |
130 |
$17K |
| D0330 |
Panoramic radiographic image |
213 |
210 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
233 |
233 |
$9K |
| D0274 |
Bitewings - four radiographic images |
299 |
298 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
168 |
164 |
$7K |
| D1120 |
Prophylaxis - child |
116 |
116 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
57 |
37 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
137 |
133 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
26 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
16 |
16 |
$342.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$300.00 |