| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
376 |
375 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
184 |
122 |
$10K |
| D0274 |
Bitewings - four radiographic images |
319 |
319 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
247 |
247 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
243 |
243 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
325 |
320 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
54 |
54 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
281 |
270 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
38 |
25 |
$1K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
23 |
12 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
15 |
$1K |
| D1330 |
|
180 |
180 |
$205.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$184.72 |