| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,600 |
1,600 |
$78K |
| D0120 |
Periodic oral evaluation - established patient |
1,508 |
1,508 |
$34K |
| D1208 |
Topical application of fluoride, excluding varnish |
815 |
815 |
$13K |
| D0274 |
Bitewings - four radiographic images |
514 |
514 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
131 |
89 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
81 |
81 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
32 |
24 |
$2K |
| D0272 |
Bitewings - two radiographic images |
127 |
127 |
$2K |
| D1206 |
Topical application of fluoride varnish |
116 |
116 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
21 |
13 |
$2K |
| D1120 |
Prophylaxis - child |
38 |
38 |
$1K |
| D0330 |
Panoramic radiographic image |
24 |
24 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$153.96 |