| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
133 |
133 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
62 |
41 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
71 |
44 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
129 |
129 |
$3K |
| D0272 |
Bitewings - two radiographic images |
171 |
171 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
38 |
18 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
202 |
200 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
191 |
191 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
52 |
52 |
$2K |
| D1120 |
Prophylaxis - child |
51 |
51 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
74 |
74 |
$1K |