| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
752 |
752 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
978 |
978 |
$20K |
| D7140 |
Extraction, erupted tooth or exposed root |
250 |
149 |
$18K |
| D0274 |
Bitewings - four radiographic images |
526 |
525 |
$15K |
| D0330 |
Panoramic radiographic image |
359 |
359 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
221 |
145 |
$12K |
| D1120 |
Prophylaxis - child |
374 |
374 |
$11K |
| D1330 |
|
1,149 |
1,149 |
$10K |
| D1310 |
|
1,138 |
1,138 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
157 |
115 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
503 |
503 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
189 |
184 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
274 |
274 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
112 |
108 |
$898.02 |
| D0272 |
Bitewings - two radiographic images |
49 |
49 |
$812.26 |