| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
714 |
714 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
719 |
719 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
850 |
850 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
195 |
115 |
$11K |
| D0274 |
Bitewings - four radiographic images |
314 |
314 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
310 |
296 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
398 |
382 |
$6K |
| D0330 |
Panoramic radiographic image |
80 |
80 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
16 |
15 |
$1K |
| D1120 |
Prophylaxis - child |
24 |
24 |
$648.60 |
| D0602 |
|
41 |
41 |
$350.61 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$348.60 |