| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
249 |
249 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
379 |
379 |
$9K |
| D0274 |
Bitewings - four radiographic images |
342 |
342 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
193 |
191 |
$6K |
| D0330 |
Panoramic radiographic image |
318 |
318 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
583 |
564 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
117 |
54 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
112 |
112 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
596 |
380 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
49 |
49 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
40 |
28 |
$2K |
| D1120 |
Prophylaxis - child |
44 |
44 |
$2K |
| D1206 |
Topical application of fluoride varnish |
48 |
48 |
$1K |