| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0274 |
Bitewings - four radiographic images |
836 |
834 |
$22K |
| D1110 |
Prophylaxis - adult |
679 |
679 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
306 |
147 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
361 |
135 |
$15K |
| D0330 |
Panoramic radiographic image |
362 |
361 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
486 |
483 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
426 |
426 |
$8K |
| D9110 |
|
113 |
112 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
169 |
169 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
45 |
13 |
$2K |
| D9920 |
|
57 |
57 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
224 |
214 |
$2K |
| D1120 |
Prophylaxis - child |
72 |
72 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$744.40 |
| D1330 |
|
121 |
121 |
$585.00 |
| D0272 |
Bitewings - two radiographic images |
40 |
40 |
$577.20 |
| D0601 |
|
54 |
54 |
$540.00 |
| D0603 |
|
12 |
12 |
$120.00 |