| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
5,220 |
5,208 |
$187K |
| D0120 |
Periodic oral evaluation - established patient |
6,791 |
6,779 |
$134K |
| D0274 |
Bitewings - four radiographic images |
4,746 |
4,744 |
$91K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,526 |
980 |
$84K |
| D0220 |
Intraoral - periapical first radiographic image |
3,920 |
3,918 |
$35K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,352 |
2,346 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,752 |
3,748 |
$23K |
| D1120 |
Prophylaxis - child |
728 |
726 |
$22K |
| D0210 |
Intraoral - complete series of radiographic images |
356 |
354 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
131 |
90 |
$8K |
| D2750 |
|
14 |
13 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
60 |
46 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
52 |
42 |
$2K |
| D0272 |
Bitewings - two radiographic images |
30 |
30 |
$361.45 |