| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
481 |
464 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
650 |
611 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
162 |
106 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
178 |
174 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
138 |
75 |
$6K |
| D1120 |
Prophylaxis - child |
274 |
249 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
294 |
279 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
147 |
138 |
$3K |
| D0274 |
Bitewings - four radiographic images |
154 |
147 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
243 |
221 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$1K |
| D1206 |
Topical application of fluoride varnish |
78 |
74 |
$988.77 |