| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
459 |
454 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
787 |
781 |
$16K |
| D0274 |
Bitewings - four radiographic images |
610 |
602 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
152 |
93 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
510 |
500 |
$11K |
| D1120 |
Prophylaxis - child |
172 |
172 |
$7K |
| D4355 |
|
132 |
130 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
202 |
201 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
563 |
545 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
113 |
112 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
50 |
43 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
14 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
13 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
116 |
73 |
$741.70 |