| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,197 |
1,028 |
$55K |
| D0210 |
Intraoral - complete series of radiographic images |
720 |
641 |
$41K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
868 |
751 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
488 |
394 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
144 |
72 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
57 |
27 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
69 |
13 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
198 |
183 |
$4K |
| D1120 |
Prophylaxis - child |
99 |
97 |
$4K |
| D0274 |
Bitewings - four radiographic images |
127 |
98 |
$3K |