| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
529 |
516 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
553 |
533 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
145 |
77 |
$9K |
| D1206 |
Topical application of fluoride varnish |
563 |
548 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
123 |
59 |
$6K |
| D1110 |
Prophylaxis - adult |
152 |
147 |
$6K |
| D0272 |
Bitewings - two radiographic images |
258 |
253 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
116 |
113 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
45 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
40 |
39 |
$960.00 |
| D0330 |
Panoramic radiographic image |
13 |
12 |
$378.00 |