| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,254 |
1,246 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
1,746 |
1,732 |
$35K |
| D7140 |
Extraction, erupted tooth or exposed root |
395 |
238 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
362 |
259 |
$20K |
| D1120 |
Prophylaxis - child |
591 |
591 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
712 |
712 |
$13K |
| D0330 |
Panoramic radiographic image |
317 |
314 |
$11K |
| D0274 |
Bitewings - four radiographic images |
393 |
391 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
152 |
111 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
275 |
273 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
146 |
143 |
$1K |
| D0272 |
Bitewings - two radiographic images |
64 |
64 |
$1K |
| D1999 |
|
16 |
15 |
$10.00 |