| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
100 |
100 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
130 |
130 |
$4K |
| D0274 |
Bitewings - four radiographic images |
119 |
119 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
186 |
186 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
49 |
31 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
37 |
24 |
$3K |
| D1120 |
Prophylaxis - child |
81 |
81 |
$2K |
| D1351 |
Sealant - per tooth |
94 |
23 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
207 |
206 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
183 |
183 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
33 |
17 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
54 |
54 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
41 |
40 |
$1K |
| D0272 |
Bitewings - two radiographic images |
44 |
44 |
$825.30 |