| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
599 |
568 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
1,035 |
966 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
112 |
95 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
87 |
49 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
67 |
55 |
$4K |
| D1120 |
Prophylaxis - child |
140 |
122 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
171 |
153 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
43 |
28 |
$2K |
| D0274 |
Bitewings - four radiographic images |
107 |
101 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
61 |
52 |
$278.50 |