| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
220 |
214 |
$10K |
| D2394 |
|
77 |
63 |
$8K |
| D0274 |
Bitewings - four radiographic images |
313 |
304 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
85 |
66 |
$7K |
| D0330 |
Panoramic radiographic image |
108 |
105 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
179 |
173 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
89 |
28 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
186 |
182 |
$5K |
| D2335 |
|
51 |
28 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
173 |
167 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
555 |
535 |
$3K |
| D4342 |
|
52 |
12 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
520 |
405 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
12 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
13 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$195.00 |