| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,861 |
1,856 |
$100K |
| D0330 |
Panoramic radiographic image |
1,197 |
1,194 |
$44K |
| D0274 |
Bitewings - four radiographic images |
1,387 |
1,381 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
391 |
308 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
756 |
755 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
707 |
705 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
273 |
205 |
$14K |
| D9110 |
|
414 |
406 |
$11K |
| D1120 |
Prophylaxis - child |
113 |
112 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
38 |
31 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
164 |
163 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
114 |
114 |
$1K |
| D0180 |
|
258 |
258 |
$225.00 |