| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
621 |
620 |
$22K |
| D1110 |
Prophylaxis - adult |
557 |
552 |
$19K |
| D0274 |
Bitewings - four radiographic images |
655 |
653 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
221 |
29 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
224 |
96 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
424 |
423 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
385 |
383 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
66 |
32 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
116 |
116 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
22 |
15 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
140 |
136 |
$896.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
26 |
26 |
$320.00 |