| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
259 |
259 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
425 |
425 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
74 |
53 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
90 |
90 |
$5K |
| D0274 |
Bitewings - four radiographic images |
147 |
147 |
$4K |
| D1206 |
Topical application of fluoride varnish |
226 |
226 |
$4K |
| D1120 |
Prophylaxis - child |
126 |
126 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
32 |
26 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
50 |
50 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
125 |
125 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
12 |
$757.50 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$204.80 |