| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
624 |
623 |
$33K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
278 |
144 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
591 |
591 |
$16K |
| D0274 |
Bitewings - four radiographic images |
370 |
369 |
$9K |
| D0330 |
Panoramic radiographic image |
251 |
250 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
126 |
47 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
61 |
34 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
93 |
56 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
113 |
112 |
$3K |
| D1120 |
Prophylaxis - child |
53 |
53 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
146 |
144 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
87 |
86 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
30 |
30 |
$418.60 |
| D0230 |
Intraoral - periapical each additional radiographic image |
42 |
30 |
$400.00 |
| D9991 |
|
23 |
23 |
$322.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$204.00 |