| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
672 |
671 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
390 |
192 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
245 |
142 |
$14K |
| D0330 |
Panoramic radiographic image |
391 |
390 |
$14K |
| D0274 |
Bitewings - four radiographic images |
510 |
508 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
157 |
39 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
457 |
456 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
457 |
457 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
50 |
50 |
$917.28 |
| D0220 |
Intraoral - periapical first radiographic image |
108 |
108 |
$716.00 |
| D1206 |
Topical application of fluoride varnish |
29 |
29 |
$487.41 |
| D1120 |
Prophylaxis - child |
14 |
14 |
$390.00 |