| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,337 |
1,333 |
$46K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
632 |
306 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
1,584 |
1,577 |
$30K |
| D0274 |
Bitewings - four radiographic images |
857 |
856 |
$23K |
| D7140 |
Extraction, erupted tooth or exposed root |
305 |
111 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
324 |
176 |
$17K |
| D0330 |
Panoramic radiographic image |
360 |
359 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
487 |
484 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
135 |
103 |
$8K |
| D1120 |
Prophylaxis - child |
198 |
195 |
$6K |
| D2330 |
|
86 |
43 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
365 |
361 |
$3K |
| D9110 |
|
96 |
96 |
$3K |
| D2332 |
|
31 |
15 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
82 |
82 |
$2K |
| D2331 |
|
18 |
13 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
38 |
37 |
$464.00 |