| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,177 |
1,164 |
$41K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
678 |
405 |
$40K |
| D0330 |
Panoramic radiographic image |
657 |
652 |
$24K |
| D0274 |
Bitewings - four radiographic images |
858 |
852 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
995 |
991 |
$21K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
292 |
138 |
$19K |
| D1120 |
Prophylaxis - child |
515 |
513 |
$15K |
| D7140 |
Extraction, erupted tooth or exposed root |
242 |
108 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
288 |
182 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
291 |
288 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
516 |
512 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
562 |
559 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
143 |
124 |
$9K |
| D9110 |
|
204 |
199 |
$6K |
| D0272 |
Bitewings - two radiographic images |
340 |
340 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
559 |
553 |
$4K |
| D2331 |
|
19 |
14 |
$900.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
67 |
56 |
$528.00 |
| D1206 |
Topical application of fluoride varnish |
27 |
27 |
$505.50 |
| D1999 |
|
145 |
106 |
$0.00 |