| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
494 |
485 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
65 |
27 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
255 |
223 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
60 |
59 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
15 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
39 |
39 |
$835.95 |
| D1110 |
Prophylaxis - adult |
15 |
15 |
$595.20 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$368.55 |