| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
61 |
27 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
52 |
38 |
$5K |
| D1110 |
Prophylaxis - adult |
49 |
42 |
$3K |
| D0330 |
Panoramic radiographic image |
33 |
24 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
51 |
41 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
53 |
45 |
$2K |
| D1206 |
Topical application of fluoride varnish |
53 |
46 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
32 |
28 |
$1K |
| D0274 |
Bitewings - four radiographic images |
34 |
30 |
$980.06 |
| D1120 |
Prophylaxis - child |
24 |
24 |
$922.99 |
| D0220 |
Intraoral - periapical first radiographic image |
20 |
15 |
$144.48 |
| D0603 |
|
17 |
14 |
$0.00 |