| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
567 |
502 |
$19K |
| D0274 |
Bitewings - four radiographic images |
638 |
564 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
203 |
120 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
409 |
365 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
297 |
256 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
709 |
621 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
648 |
567 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
27 |
15 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
13 |
12 |
$780.00 |
| D1320 |
|
29 |
29 |
$521.91 |
| D1206 |
Topical application of fluoride varnish |
26 |
25 |
$427.23 |
| D0601 |
|
28 |
27 |
$250.00 |
| D1330 |
|
48 |
47 |
$236.08 |
| D1310 |
|
12 |
12 |
$55.00 |