| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,469 |
1,469 |
$78K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
942 |
533 |
$77K |
| D0120 |
Periodic oral evaluation - established patient |
1,302 |
1,301 |
$35K |
| D0274 |
Bitewings - four radiographic images |
834 |
833 |
$29K |
| D0330 |
Panoramic radiographic image |
612 |
612 |
$27K |
| D1120 |
Prophylaxis - child |
660 |
660 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
790 |
790 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
418 |
243 |
$22K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
171 |
125 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,070 |
1,070 |
$15K |
| D7140 |
Extraction, erupted tooth or exposed root |
189 |
86 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
131 |
131 |
$9K |
| D2332 |
|
17 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
59 |
59 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
58 |
58 |
$707.80 |