| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
700 |
700 |
$36K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
189 |
111 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
564 |
564 |
$15K |
| D0274 |
Bitewings - four radiographic images |
401 |
401 |
$10K |
| D4341 |
|
158 |
67 |
$8K |
| D0330 |
Panoramic radiographic image |
225 |
225 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
42 |
29 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
44 |
29 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
85 |
85 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
133 |
132 |
$1K |
| D1120 |
Prophylaxis - child |
14 |
14 |
$574.05 |
| D1208 |
Topical application of fluoride, excluding varnish |
34 |
34 |
$457.10 |
| D1999 |
|
19 |
19 |
$0.00 |