| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,339 |
3,334 |
$120K |
| D0120 |
Periodic oral evaluation - established patient |
4,210 |
4,206 |
$82K |
| D0210 |
Intraoral - complete series of radiographic images |
2,154 |
2,147 |
$63K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,197 |
592 |
$47K |
| D0274 |
Bitewings - four radiographic images |
1,908 |
1,908 |
$36K |
| D0220 |
Intraoral - periapical first radiographic image |
2,523 |
2,518 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,167 |
2,120 |
$18K |
| D2954 |
|
84 |
75 |
$7K |
| D2330 |
|
200 |
92 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
115 |
96 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
145 |
102 |
$6K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
17 |
15 |
$6K |
| D1120 |
Prophylaxis - child |
179 |
179 |
$6K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
14 |
14 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
222 |
222 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$130.86 |