| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
215 |
215 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
110 |
28 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
266 |
266 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
124 |
84 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
99 |
77 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
121 |
121 |
$3K |
| D0274 |
Bitewings - four radiographic images |
143 |
143 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
82 |
82 |
$2K |
| D0330 |
Panoramic radiographic image |
77 |
77 |
$2K |
| D1110 |
Prophylaxis - adult |
40 |
40 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
48 |
47 |
$898.64 |
| D0220 |
Intraoral - periapical first radiographic image |
94 |
92 |
$614.73 |
| D0272 |
Bitewings - two radiographic images |
44 |
44 |
$422.56 |
| D0230 |
Intraoral - periapical each additional radiographic image |
26 |
26 |
$147.84 |