| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
215 |
215 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
277 |
277 |
$9K |
| D0330 |
Panoramic radiographic image |
125 |
125 |
$9K |
| D1120 |
Prophylaxis - child |
162 |
162 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
194 |
194 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
110 |
110 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
49 |
37 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
32 |
13 |
$4K |
| D0274 |
Bitewings - four radiographic images |
67 |
67 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
50 |
50 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
16 |
$2K |
| D0272 |
Bitewings - two radiographic images |
32 |
32 |
$606.15 |