| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,567 |
1,564 |
$61K |
| D0120 |
Periodic oral evaluation - established patient |
1,994 |
1,990 |
$39K |
| D0274 |
Bitewings - four radiographic images |
536 |
536 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
925 |
925 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
235 |
235 |
$10K |
| D0272 |
Bitewings - two radiographic images |
639 |
638 |
$7K |
| D1120 |
Prophylaxis - child |
193 |
193 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
453 |
453 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
258 |
258 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
34 |
14 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
34 |
14 |
$1K |