| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
802 |
801 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
610 |
609 |
$17K |
| D0274 |
Bitewings - four radiographic images |
374 |
374 |
$12K |
| D0330 |
Panoramic radiographic image |
277 |
277 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
136 |
96 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
364 |
364 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
156 |
63 |
$8K |
| D1120 |
Prophylaxis - child |
133 |
133 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
317 |
307 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
92 |
92 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
87 |
87 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
13 |
$1K |
| D0272 |
Bitewings - two radiographic images |
26 |
26 |
$454.25 |