| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,445 |
1,427 |
$61K |
| D0120 |
Periodic oral evaluation - established patient |
2,549 |
2,516 |
$60K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,054 |
2,039 |
$40K |
| D0274 |
Bitewings - four radiographic images |
1,366 |
1,350 |
$35K |
| D1120 |
Prophylaxis - child |
1,015 |
1,012 |
$33K |
| D0140 |
Limited oral evaluation - problem focused |
724 |
691 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
209 |
137 |
$15K |
| D7140 |
Extraction, erupted tooth or exposed root |
96 |
68 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
444 |
425 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
46 |
27 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
47 |
27 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
71 |
71 |
$2K |
| D0330 |
Panoramic radiographic image |
41 |
41 |
$2K |
| D0272 |
Bitewings - two radiographic images |
26 |
26 |
$475.91 |