| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1355 |
|
10,460 |
431 |
$358K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,620 |
1,598 |
$42K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
367 |
82 |
$28K |
| D1120 |
Prophylaxis - child |
742 |
740 |
$22K |
| D1110 |
Prophylaxis - adult |
377 |
365 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
779 |
779 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
147 |
61 |
$12K |
| D1206 |
Topical application of fluoride varnish |
411 |
410 |
$9K |
| D0330 |
Panoramic radiographic image |
92 |
92 |
$4K |
| D0470 |
|
13 |
13 |
$881.40 |
| D0274 |
Bitewings - four radiographic images |
29 |
28 |
$800.40 |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$302.25 |