| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
297 |
294 |
$16K |
| D1110 |
Prophylaxis - adult |
359 |
359 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
196 |
145 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
522 |
522 |
$11K |
| D0274 |
Bitewings - four radiographic images |
162 |
162 |
$4K |
| D1206 |
Topical application of fluoride varnish |
167 |
167 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
339 |
332 |
$3K |
| D1120 |
Prophylaxis - child |
70 |
70 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
41 |
28 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
83 |
83 |
$2K |
| D9920 |
|
12 |
12 |
$2K |
| D0330 |
Panoramic radiographic image |
29 |
29 |
$1K |
| D1330 |
|
75 |
75 |
$452.81 |
| D0270 |
|
12 |
12 |
$96.00 |