| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
158 |
158 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
110 |
110 |
$6K |
| D1110 |
Prophylaxis - adult |
74 |
74 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
84 |
79 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
27 |
12 |
$4K |
| D1206 |
Topical application of fluoride varnish |
134 |
134 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
12 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
65 |
65 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
33 |
29 |
$390.06 |