| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
501 |
475 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
982 |
897 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
598 |
332 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
318 |
292 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
102 |
50 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
122 |
69 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
212 |
200 |
$7K |
| D0274 |
Bitewings - four radiographic images |
156 |
145 |
$5K |
| D0330 |
Panoramic radiographic image |
84 |
81 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
107 |
99 |
$3K |
| D1206 |
Topical application of fluoride varnish |
54 |
53 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
12 |
$2K |
| D1120 |
Prophylaxis - child |
25 |
24 |
$889.26 |