| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
605 |
605 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
414 |
414 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
135 |
105 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
298 |
298 |
$10K |
| D0274 |
Bitewings - four radiographic images |
262 |
262 |
$9K |
| D0330 |
Panoramic radiographic image |
123 |
123 |
$6K |
| D1120 |
Prophylaxis - child |
90 |
90 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
38 |
38 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
149 |
148 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
136 |
136 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
21 |
13 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
100 |
100 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
13 |
$868.92 |