| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
149 |
149 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
130 |
130 |
$5K |
| D0274 |
Bitewings - four radiographic images |
172 |
172 |
$5K |
| D2140 |
|
84 |
56 |
$4K |
| D0330 |
Panoramic radiographic image |
93 |
93 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
287 |
279 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
38 |
27 |
$3K |
| D1206 |
Topical application of fluoride varnish |
172 |
172 |
$3K |
| D1120 |
Prophylaxis - child |
72 |
72 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
108 |
108 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
33 |
27 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
223 |
223 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
29 |
21 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
15 |
15 |
$532.20 |