| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
424 |
424 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
394 |
394 |
$8K |
| D0274 |
Bitewings - four radiographic images |
238 |
238 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
73 |
52 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
160 |
159 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
320 |
301 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
124 |
124 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
29 |
14 |
$2K |
| D1120 |
Prophylaxis - child |
37 |
37 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
14 |
$912.45 |
| D9110 |
|
26 |
26 |
$780.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
53 |
44 |
$424.00 |