| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
496 |
496 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
589 |
589 |
$12K |
| D0274 |
Bitewings - four radiographic images |
288 |
288 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
210 |
210 |
$4K |
| D1120 |
Prophylaxis - child |
68 |
68 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
30 |
26 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
202 |
200 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
54 |
54 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
15 |
15 |
$555.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
12 |
$104.00 |