| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,253 |
2,252 |
$123K |
| D0274 |
Bitewings - four radiographic images |
2,068 |
2,068 |
$57K |
| D0120 |
Periodic oral evaluation - established patient |
1,884 |
1,882 |
$51K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
763 |
763 |
$23K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
120 |
69 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
362 |
362 |
$11K |
| D0330 |
Panoramic radiographic image |
297 |
297 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
132 |
92 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
67 |
52 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
313 |
313 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
317 |
313 |
$4K |
| D1120 |
Prophylaxis - child |
44 |
44 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
51 |
50 |
$491.90 |