| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
861 |
860 |
$48K |
| D1120 |
Prophylaxis - child |
649 |
649 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
330 |
291 |
$27K |
| D0330 |
Panoramic radiographic image |
533 |
533 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
654 |
654 |
$20K |
| D0274 |
Bitewings - four radiographic images |
502 |
502 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
262 |
157 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
326 |
326 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
580 |
569 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
413 |
410 |
$7K |
| D1206 |
Topical application of fluoride varnish |
180 |
180 |
$5K |
| D0272 |
Bitewings - two radiographic images |
234 |
234 |
$5K |
| D1351 |
Sealant - per tooth |
138 |
49 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
60 |
53 |
$3K |
| D1320 |
|
49 |
49 |
$467.50 |
| D9995 |
|
29 |
29 |
$0.00 |