| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
600 |
594 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
917 |
911 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
158 |
92 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
131 |
82 |
$8K |
| D0272 |
Bitewings - two radiographic images |
382 |
374 |
$6K |
| D2332 |
|
77 |
54 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
238 |
238 |
$4K |
| D1120 |
Prophylaxis - child |
123 |
123 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
40 |
25 |
$2K |
| D1330 |
|
99 |
99 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
82 |
80 |
$630.05 |