| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
206 |
157 |
$12K |
| D0330 |
Panoramic radiographic image |
340 |
332 |
$12K |
| D1110 |
Prophylaxis - adult |
234 |
229 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
396 |
386 |
$7K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
73 |
52 |
$5K |
| D9110 |
|
66 |
61 |
$1K |
| D1120 |
Prophylaxis - child |
30 |
30 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
30 |
30 |
$413.55 |
| D0220 |
Intraoral - periapical first radiographic image |
46 |
45 |
$319.12 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$289.92 |