| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
393 |
391 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
545 |
543 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
223 |
127 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
67 |
27 |
$4K |
| D0272 |
Bitewings - two radiographic images |
236 |
234 |
$4K |
| D1120 |
Prophylaxis - child |
115 |
115 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
52 |
40 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
142 |
140 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
41 |
39 |
$312.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$240.00 |