| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
633 |
622 |
$21K |
| D0274 |
Bitewings - four radiographic images |
534 |
529 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
173 |
68 |
$10K |
| D2332 |
|
142 |
27 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
413 |
410 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
102 |
52 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
558 |
543 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
202 |
194 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
508 |
496 |
$4K |
| D0330 |
Panoramic radiographic image |
65 |
61 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
27 |
12 |
$2K |
| D1310 |
|
155 |
150 |
$1K |
| D1330 |
|
148 |
143 |
$1K |
| D9110 |
|
12 |
12 |
$360.00 |