| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
668 |
663 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
758 |
753 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
176 |
84 |
$10K |
| D0272 |
Bitewings - two radiographic images |
154 |
153 |
$2K |
| D1120 |
Prophylaxis - child |
72 |
72 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
45 |
29 |
$2K |
| D0274 |
Bitewings - four radiographic images |
78 |
76 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
67 |
67 |
$1K |
| D1330 |
|
115 |
114 |
$1K |
| D1310 |
|
115 |
114 |
$1K |
| D1206 |
Topical application of fluoride varnish |
45 |
45 |
$810.00 |
| D0220 |
Intraoral - periapical first radiographic image |
71 |
70 |
$541.00 |