| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,117 |
2,103 |
$104K |
| D0120 |
Periodic oral evaluation - established patient |
3,355 |
3,337 |
$95K |
| D1120 |
Prophylaxis - child |
1,955 |
1,948 |
$71K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,012 |
2,996 |
$62K |
| D0272 |
Bitewings - two radiographic images |
1,984 |
1,962 |
$42K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
371 |
198 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
416 |
411 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
249 |
163 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
138 |
128 |
$2K |
| D1206 |
Topical application of fluoride varnish |
47 |
47 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
27 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
21 |
12 |
$198.72 |