| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
653 |
653 |
$28K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
654 |
274 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
705 |
705 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
291 |
175 |
$15K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
40 |
24 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
916 |
915 |
$10K |
| D0272 |
Bitewings - two radiographic images |
713 |
713 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
748 |
748 |
$4K |
| D1120 |
Prophylaxis - child |
74 |
74 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
45 |
37 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
105 |
105 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
42 |
42 |
$957.00 |
| D0330 |
Panoramic radiographic image |
28 |
28 |
$956.00 |