| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,037 |
1,022 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,990 |
1,965 |
$33K |
| D1120 |
Prophylaxis - child |
1,034 |
1,027 |
$20K |
| D0274 |
Bitewings - four radiographic images |
519 |
512 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
596 |
589 |
$9K |
| D1206 |
Topical application of fluoride varnish |
536 |
531 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
147 |
72 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
141 |
53 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
205 |
192 |
$4K |
| D0272 |
Bitewings - two radiographic images |
406 |
403 |
$4K |
| D0330 |
Panoramic radiographic image |
26 |
26 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
12 |
12 |
$780.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
12 |
$768.15 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$316.20 |
| D0220 |
Intraoral - periapical first radiographic image |
64 |
62 |
$307.00 |