| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,287 |
1,287 |
$63K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
525 |
319 |
$46K |
| D0274 |
Bitewings - four radiographic images |
1,125 |
1,125 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
850 |
850 |
$19K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
108 |
75 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
204 |
204 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
94 |
63 |
$6K |
| D1206 |
Topical application of fluoride varnish |
189 |
189 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
20 |
14 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
159 |
157 |
$2K |
| D0330 |
Panoramic radiographic image |
27 |
27 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$441.60 |
| D0230 |
Intraoral - periapical each additional radiographic image |
26 |
26 |
$250.54 |