| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,273 |
1,251 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
1,475 |
1,459 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
110 |
85 |
$9K |
| D1206 |
Topical application of fluoride varnish |
528 |
518 |
$9K |
| D0330 |
Panoramic radiographic image |
118 |
117 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
181 |
180 |
$5K |
| D0274 |
Bitewings - four radiographic images |
221 |
209 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
129 |
123 |
$4K |
| D1120 |
Prophylaxis - child |
103 |
102 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
148 |
148 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
32 |
26 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
33 |
13 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
123 |
116 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
17 |
12 |
$476.06 |