| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
883 |
883 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
468 |
249 |
$25K |
| D0274 |
Bitewings - four radiographic images |
726 |
725 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
908 |
907 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
273 |
122 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
256 |
143 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
196 |
96 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
802 |
801 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
757 |
756 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
291 |
291 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
113 |
113 |
$5K |
| D2332 |
|
53 |
25 |
$3K |
| D2330 |
|
53 |
25 |
$2K |
| D0601 |
|
86 |
86 |
$860.00 |
| D1330 |
|
158 |
158 |
$775.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
26 |
26 |
$474.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$451.40 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$360.00 |