| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
331 |
331 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
385 |
385 |
$7K |
| D0274 |
Bitewings - four radiographic images |
256 |
256 |
$7K |
| D1330 |
|
410 |
410 |
$5K |
| D1310 |
|
411 |
411 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
60 |
26 |
$4K |
| D0330 |
Panoramic radiographic image |
98 |
98 |
$3K |
| D1120 |
Prophylaxis - child |
86 |
86 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
134 |
134 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
44 |
43 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
35 |
24 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
98 |
98 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
14 |
$900.00 |
| D0220 |
Intraoral - periapical first radiographic image |
26 |
26 |
$168.00 |