| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
770 |
768 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
524 |
333 |
$35K |
| D0274 |
Bitewings - four radiographic images |
1,041 |
1,039 |
$24K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
262 |
176 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
594 |
584 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
472 |
468 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,248 |
1,213 |
$13K |
| D1206 |
Topical application of fluoride varnish |
606 |
604 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
192 |
130 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
305 |
305 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
884 |
861 |
$6K |
| D0330 |
Panoramic radiographic image |
115 |
114 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
26 |
13 |
$2K |
| D4355 |
|
37 |
37 |
$2K |
| D2394 |
|
15 |
12 |
$1K |
| D1320 |
|
38 |
38 |
$350.00 |