| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
249 |
245 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
90 |
87 |
$6K |
| D0274 |
Bitewings - four radiographic images |
153 |
153 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
225 |
222 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
63 |
16 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
111 |
109 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
260 |
254 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
84 |
82 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
46 |
26 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
245 |
182 |
$3K |
| D1206 |
Topical application of fluoride varnish |
101 |
100 |
$3K |
| D1120 |
Prophylaxis - child |
50 |
48 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
13 |
$1K |