| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,751 |
1,702 |
$58K |
| D0120 |
Periodic oral evaluation - established patient |
2,933 |
2,815 |
$49K |
| D1120 |
Prophylaxis - child |
1,287 |
1,211 |
$33K |
| D0274 |
Bitewings - four radiographic images |
1,078 |
1,043 |
$25K |
| D1206 |
Topical application of fluoride varnish |
1,402 |
1,317 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
173 |
115 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
100 |
37 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
224 |
216 |
$5K |
| D4910 |
|
65 |
63 |
$4K |
| D0272 |
Bitewings - two radiographic images |
153 |
143 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
13 |
$1K |
| D0330 |
Panoramic radiographic image |
25 |
24 |
$897.31 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
12 |
$136.81 |