| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
208 |
207 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
134 |
75 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
143 |
76 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
270 |
268 |
$5K |
| D0274 |
Bitewings - four radiographic images |
218 |
217 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
244 |
237 |
$4K |
| D4341 |
|
60 |
18 |
$2K |
| D2331 |
|
33 |
17 |
$2K |
| D1351 |
Sealant - per tooth |
81 |
17 |
$2K |
| D1120 |
Prophylaxis - child |
61 |
59 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
23 |
17 |
$2K |
| D2330 |
|
30 |
18 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
117 |
115 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
80 |
79 |
$978.36 |
| D7140 |
Extraction, erupted tooth or exposed root |
15 |
13 |
$598.50 |
| D0272 |
Bitewings - two radiographic images |
42 |
42 |
$470.71 |
| D9110 |
|
21 |
21 |
$405.09 |