| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
270 |
269 |
$6K |
| D0330 |
Panoramic radiographic image |
105 |
105 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
63 |
29 |
$3K |
| D1110 |
Prophylaxis - adult |
84 |
84 |
$3K |
| D1206 |
Topical application of fluoride varnish |
145 |
145 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
116 |
116 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
29 |
12 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
29 |
13 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
41 |
41 |
$1K |
| D0274 |
Bitewings - four radiographic images |
61 |
59 |
$917.20 |
| D1120 |
Prophylaxis - child |
38 |
38 |
$760.00 |
| D0220 |
Intraoral - periapical first radiographic image |
137 |
132 |
$675.00 |