| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0274 |
Bitewings - four radiographic images |
729 |
726 |
$19K |
| D1110 |
Prophylaxis - adult |
554 |
553 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
337 |
142 |
$15K |
| D0330 |
Panoramic radiographic image |
323 |
323 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
461 |
458 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
136 |
28 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
348 |
348 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
755 |
751 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
763 |
761 |
$6K |
| D2330 |
|
80 |
41 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
54 |
53 |
$845.12 |
| D1120 |
Prophylaxis - child |
19 |
19 |
$422.90 |