| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,676 |
2,648 |
$132K |
| D0120 |
Periodic oral evaluation - established patient |
3,262 |
3,226 |
$82K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
541 |
413 |
$74K |
| D0274 |
Bitewings - four radiographic images |
1,163 |
1,156 |
$36K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
203 |
169 |
$33K |
| D2740 |
Crown - porcelain/ceramic |
28 |
24 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
724 |
694 |
$9K |
| D1206 |
Topical application of fluoride varnish |
287 |
286 |
$7K |
| D2394 |
|
14 |
12 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
20 |
12 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
47 |
47 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
102 |
102 |
$1K |
| D4910 |
|
12 |
12 |
$887.88 |
| D4346 |
|
12 |
12 |
$667.64 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$452.07 |