| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,902 |
1,902 |
$81K |
| D0120 |
Periodic oral evaluation - established patient |
2,800 |
2,800 |
$66K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,353 |
2,344 |
$32K |
| D0274 |
Bitewings - four radiographic images |
1,304 |
1,304 |
$32K |
| D1120 |
Prophylaxis - child |
914 |
914 |
$30K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
404 |
239 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,683 |
1,683 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
408 |
408 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
342 |
212 |
$15K |
| D0272 |
Bitewings - two radiographic images |
657 |
657 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
511 |
507 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
49 |
28 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
80 |
47 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
43 |
43 |
$506.35 |