| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,167 |
2,166 |
$117K |
| D0120 |
Periodic oral evaluation - established patient |
2,315 |
2,312 |
$60K |
| D0330 |
Panoramic radiographic image |
1,022 |
1,020 |
$37K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
432 |
299 |
$34K |
| D0272 |
Bitewings - two radiographic images |
1,683 |
1,679 |
$26K |
| D7140 |
Extraction, erupted tooth or exposed root |
471 |
196 |
$25K |
| D0274 |
Bitewings - four radiographic images |
796 |
796 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
326 |
210 |
$16K |
| D1120 |
Prophylaxis - child |
332 |
332 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
561 |
561 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
28 |
22 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
322 |
316 |
$3K |
| D2330 |
|
20 |
12 |
$772.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
52 |
39 |
$250.00 |