| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
154 |
153 |
$5K |
| D0274 |
Bitewings - four radiographic images |
149 |
147 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
106 |
104 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
122 |
120 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
119 |
118 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
105 |
104 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
23 |
14 |
$1K |
| D1120 |
Prophylaxis - child |
66 |
65 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
12 |
$870.57 |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$840.00 |
| D0330 |
Panoramic radiographic image |
17 |
16 |
$741.12 |
| D0272 |
Bitewings - two radiographic images |
47 |
46 |
$440.00 |
| D0220 |
Intraoral - periapical first radiographic image |
33 |
33 |
$154.00 |