| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
203 |
203 |
$10K |
| D0274 |
Bitewings - four radiographic images |
259 |
259 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
73 |
53 |
$6K |
| D0330 |
Panoramic radiographic image |
131 |
131 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
159 |
159 |
$6K |
| D1120 |
Prophylaxis - child |
155 |
155 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
66 |
40 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
220 |
220 |
$5K |
| D1206 |
Topical application of fluoride varnish |
250 |
250 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
301 |
297 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
94 |
94 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
161 |
156 |
$1K |
| D0272 |
Bitewings - two radiographic images |
56 |
56 |
$1K |
| D0240 |
|
19 |
19 |
$359.86 |