| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
573 |
572 |
$44K |
| D4341 |
|
363 |
110 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
364 |
364 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
501 |
498 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
272 |
272 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,780 |
537 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
906 |
905 |
$10K |
| D1120 |
Prophylaxis - child |
156 |
156 |
$5K |
| D0272 |
Bitewings - two radiographic images |
276 |
276 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
50 |
27 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
178 |
174 |
$2K |
| D4910 |
|
27 |
27 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
12 |
$982.80 |