| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
807 |
806 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
610 |
609 |
$17K |
| D0274 |
Bitewings - four radiographic images |
515 |
515 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
347 |
347 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
139 |
106 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
50 |
28 |
$3K |
| D1330 |
|
835 |
828 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
15 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
66 |
66 |
$550.20 |
| D1206 |
Topical application of fluoride varnish |
26 |
26 |
$489.60 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
14 |
$475.00 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$373.00 |