| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
551 |
551 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
555 |
555 |
$15K |
| D1206 |
Topical application of fluoride varnish |
600 |
600 |
$12K |
| D0274 |
Bitewings - four radiographic images |
253 |
253 |
$10K |
| D0272 |
Bitewings - two radiographic images |
315 |
313 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
70 |
43 |
$7K |
| D1110 |
Prophylaxis - adult |
52 |
52 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
81 |
80 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
29 |
29 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
24 |
22 |
$272.83 |