| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
782 |
773 |
$40K |
| D0140 |
Limited oral evaluation - problem focused |
450 |
442 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
689 |
680 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
229 |
228 |
$16K |
| D0274 |
Bitewings - four radiographic images |
379 |
373 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
818 |
794 |
$13K |
| D1206 |
Topical application of fluoride varnish |
350 |
343 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
211 |
209 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
644 |
514 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
92 |
51 |
$8K |
| D1120 |
Prophylaxis - child |
128 |
125 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
79 |
27 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
79 |
38 |
$5K |