| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
819 |
814 |
$28K |
| D0330 |
Panoramic radiographic image |
747 |
743 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
438 |
260 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,053 |
1,047 |
$20K |
| D1120 |
Prophylaxis - child |
646 |
642 |
$19K |
| D0210 |
Intraoral - complete series of radiographic images |
425 |
423 |
$19K |
| D1206 |
Topical application of fluoride varnish |
934 |
930 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
664 |
661 |
$13K |
| D0274 |
Bitewings - four radiographic images |
474 |
470 |
$13K |
| D5110 |
|
27 |
27 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
180 |
124 |
$12K |
| D5120 |
|
24 |
24 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
124 |
46 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
755 |
619 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
819 |
810 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
102 |
75 |
$5K |
| D0272 |
Bitewings - two radiographic images |
286 |
286 |
$4K |
| D2332 |
|
69 |
42 |
$4K |
| D1310 |
|
38 |
38 |
$425.12 |
| D1330 |
|
37 |
37 |
$419.04 |
| D1999 |
|
13 |
12 |
$70.00 |