| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0274 |
Bitewings - four radiographic images |
554 |
551 |
$15K |
| D1110 |
Prophylaxis - adult |
369 |
367 |
$12K |
| D0330 |
Panoramic radiographic image |
217 |
216 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
305 |
303 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
103 |
47 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
243 |
241 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
36 |
15 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
36 |
12 |
$2K |
| D9110 |
|
41 |
41 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
70 |
70 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
138 |
134 |
$1K |
| D1310 |
|
25 |
25 |
$125.00 |
| D1330 |
|
12 |
12 |
$40.00 |