| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
534 |
520 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
871 |
848 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
217 |
174 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
209 |
127 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
237 |
233 |
$13K |
| D1120 |
Prophylaxis - child |
338 |
327 |
$10K |
| D0274 |
Bitewings - four radiographic images |
358 |
351 |
$10K |
| D1206 |
Topical application of fluoride varnish |
485 |
470 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
217 |
210 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
84 |
69 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
310 |
307 |
$2K |
| D9920 |
|
14 |
14 |
$2K |
| D0272 |
Bitewings - two radiographic images |
56 |
56 |
$921.76 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$456.95 |
| D1330 |
|
25 |
25 |
$222.56 |
| D0230 |
Intraoral - periapical each additional radiographic image |
15 |
15 |
$181.96 |