| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
978 |
975 |
$32K |
| D0274 |
Bitewings - four radiographic images |
899 |
896 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
1,219 |
1,216 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
275 |
200 |
$15K |
| D9110 |
|
431 |
417 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,511 |
1,466 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,374 |
1,319 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
200 |
110 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
69 |
53 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
216 |
216 |
$3K |
| D1120 |
Prophylaxis - child |
102 |
102 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
35 |
27 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
26 |
$1K |
| D0272 |
Bitewings - two radiographic images |
28 |
28 |
$431.28 |
| D1330 |
|
87 |
87 |
$425.00 |
| D0270 |
|
20 |
19 |
$145.63 |
| D0602 |
|
15 |
15 |
$140.00 |